After years of inaction, prior authorization may only be fixed through federal intervention
CHICAGO – More than two years after a landmark consensus statement signaled insurers were open to reforming the arduous prior authorization process, their subsequent inaction has translated into stalled progress and ongoing burdens for patients and physicians. According to new survey data released today by the American Medical Association (AMA), physicians say prior authorization continues to interfere with patient care and can lead to adverse clinical consequences, with 16% of physicians reporting that the process has led to a patient’s hospitalization. Moreover, surveyed physicians see little, if any, progress toward easing agreed-upon burdensome barriers to patient care, highlighting the need for legislative action to address a problem affecting patients across the country.
“These new survey results highlight that practices continue to devote significant time—an average of nearly two business day per week per physician—navigating prior authorization’s administrative obstacles. Even more concerning, this process can harm our patients,” said AMA President Susan R. Bailey, M.D. “Almost two and a half years after our consensus statement, the sad fact is little progress has been made toward the reform goals. The health insurance industry’s failure to achieve agreed-upon improvements illustrates a clear need for legislation like The Improving Seniors’ Timely Access to Care Act, H.R. 3107, to rein in prior authorization practices that adversely affect patient health.”
H.R. 3107, bipartisan legislation introduced by Representatives Suzan DelBene (D-WA), Mike Kelly (R-PA), Roger Marshall, M.D. (R-KS), and Ami Bera, M.D. (D-CA), would improve care delivery for America’s seniors by requiring Medicare Advantage plans to abide by many of the concepts outlined in the consensus statement, such as streamlining and standardizing prior authorization and improving transparency of health insurer programs. A bipartisan majority of more than 219 members of the House of Representatives has already co-sponsored the bill, which continues to gain support.
“My legislation will go a long way in addressing what this survey makes clear – physicians and other health care professionals are spending too much of their time dealing with burdensome and archaic prior authorization requests when they should be caring for people,” said DelBene. “Prior authorization can and should be used appropriately to guarantee appropriate patient care and avoid unnecessary costs and my legislation sets up the guardrails to make that happen and dramatically ease physician burden and burnout. Thank you to my bipartisan colleagues, Rep. Mike Kelly, Rep. Roger Marshall, and Rep. Ami Bera for being great partners through each step of this process.”
“These much-needed improvements to Medicare Advantage and the prior authorization process will ensure that medically necessary care is not delayed or denied for our seniors,” said Kelly. “I, along with my colleagues, Reps. Marshall, DelBene, and Bera, want to empower the Department of Health and Human Services to study and enhance the Medicare Advantage program by setting standards and providing more transparency over how prior authorization is utilized. There’s no question that H.R. 3107, the Improving Seniors’ Access to Timely Care Act, is a win for seniors and those that care for them.”
“As a practicing physician for over 25 years, my top priority has always been to provide quality care to my patients, and I continue to carry that charge as a policymaker,” said Dr. Marshall. “Prior authorization is a common management tool, but the current landscape doesn’t provide the best utilization of it, resulting in physician burdens and patient access issues. Our bill will bring Medicare Advantage to the 21st century by streamlining and modernizing the prior authorization process. I’m proud of the work our team has done in collaborating with patient groups, health care providers, health plans, and the administration to deliver meaningful change.”
“As a doctor, I am committed to relieving unnecessary administrative burdens on practicing physicians, which will improve quality of care for patients,” said Rep. Bera, M.D. “Physicians spend far too much time on burdensome paperwork and seeking authorization on certain items, when they can be spending that time taking care of their patients. Our bipartisan bill, H.R. 3107, modernizes the process, and is a win for physicians and patients.”
In January 2018, the AMA and other national organizations representing pharmacists, medical groups, hospitals and health plans signed a joint consensus statement that outlined five key areas for industry-wide improvements to prior authorization processes and patient-centered care. The shared commitment was signed by two trade organizations representing payers: America's Health Insurance Plans and the Blue Cross Blue Shield Association.
The newly released AMA survey results reflect the limited progress that health plans have made toward implementing each of the five areas of prior authorization reform outlined in the consensus statement.
- Selective application of requirements.
Insurers should exempt physicians with prescribing patterns that meet evidence-based guidelines or with high approval rates from prior authorization, according to the consensus statement. However, only 7% of physicians report contracting with health plans that offer programs that exempt providers from prior authorization.
- Adjustment of the volume of requirements.
Insurers should regularly review drugs and services subject to prior authorization and remove those that that show "low variation in utilization or low prior authorization denial rates," according to the consensus statement. But most physicians (87% and 82%, respectively) report the number of prescription medications and medical services needing prior authorization has grown over the past five years.
- Improved transparency.
Insurers should "encourage transparency and easy accessibility of prior authorization requirements, criteria, rationale, and program changes," the consensus statement reads. However, almost seven in 10 physicians (67%) report that it is difficult to determine whether a drug or service requires prior authorization.
- Protection for continuity of patient care.
Insurers should “minimize disruptions in needed treatment,” including “minimizing repetitive prior authorization requirements,” as stated in the consensus statement. However, most physicians (83%) report that prior authorization interferes with continuity of care, such as resulting in missed doses or interruptions in chronic treatment.
- Automation through standardized processes.
Efforts should be made to speed the adoption of existing national standards for electronic transactions for prior authorizations, according to the consensus statement. However, physicians still report phone and fax as the most commonly used methods for completing prior authorization requirements.
The AMA continues on every front to streamline prior authorization. Through our research, collaborations, advocacy and leadership, the AMA is working to make the patient‐physician relationship more valued than paperwork by right-sizing prior authorization programs. Patients can share their own personal experiences with prior authorization and send a message to Congress supporting H.R. 3107 at FixPriorAuth.org.