AMA Study Shows Prior Authorization Provisions Interfere With Care Delivery

A new report by the American Medical Association (AMA) has decried the increase in the number of prior authorization requirements (PA) over the past five years, saying this was interfering with the delivery and continuity of care.

Last year, the AMA surveyed 1,000 physicians about their experience with PA. The study revealed that prior authorizations posed significant challenges for both physicians and patients.

The study’s findings

The results revealed that 85 percent of physicians say the practice interferes with continuity of care and more than two-thirds said it is difficult for them to determine whether a prescription or service needs prior authorization.

Sixty-four percent of the physicians said they had to endure a wait of at least one business day before getting a response from a health plan regarding a prior authorization (PA) decision, while less than 10% said they contract with a health plan that allows programs to exempt providers from the requirement.

A cause for concern was that 78 percent of physicians said PA can at least sometimes lead to treatment abandonment on the part of patients. Furthermore, 92 percent of respondents said this could lead to a negative impact on patient outcomes.

The AMA said the results of the latest study come a year after health insurance trade organizations agreed to reduce unnecessary burdens and promote timely access to care by revising their PA processes to be more data-driven and transparent. Instead, the report notes that insurers have not implemented these changes widely enough making the process more burdensome and time consuming than ever.

“Physicians follow required insurance protocols for prior authorization that involve recurring paperwork, multiple phone calls and hours spent on hold. At the same time, patients’ lives can hang in the balance until health plans decide if needed care will qualify for insurance coverage,” AMA president Barbara McAneny, said.

PA is a process requiring health care providers — physicians, pharmacists, medical groups and hospitals — to obtain advance approval from health plans before a prescription medication or medical service is delivered to the patient. “While health plans and benefit managers contend that PA programs are important to control costs, providers often find these programs to be burdensome and barriers to the delivery of necessary patient care,” AMA explained.

According to the report, physicians were reporting an increase in PA volume that includes requirements for drugs and services that are neither new nor costly. This includes long-available generic drugs and prescriptions for patients on an established medication regimen to manage a chronic condition.

AMA advocates for PA process reform

The AMA has been advocating for the reform of the PA process for a while, arguing that the process was overused and presented significant administrative and clinical concerns.

As part of the process to reform PA, the AMA collaborated with the American Hospital Association, America’s Health Insurance Plans, American Pharmacists Association, Blue Cross Blue Shield Association and Medical Group Management Association in releasing the “Consensus Statement on Improving the Prior Authorization Process” in January 2018.

Under the consensus statement, it was agreed that health plans would:

• Selectively apply PA and exclude physicians who have high rates of PA approval, prescribe according to evidence-based guidelines or participate in risk-based payment contractual agreements. Yet only 8 percent of physicians surveyed reported contracting with health plans that offer programs exempting them from PA.
• Adjust the volume of PA requirements to reflect drugs and services with low variation in utilization or low PA denial rates. However, instead of experiencing a reduction in the number of drugs requiring PA, 88 percent of physicians said the number has gone up. Similarly, 86 percent of physicians reported that the number of services requiring PA has gone up, too.
• Improve transparency and clearly articulate PA criteria, rationale and program changes. But 69 percent of physicians reported it was difficult to determine which medications or services required PA.
• Protect continuity of patient care by ensuring continued access to effective treatment during health plan or coverage changes and eliminating repetitive PA requirements. Surveyed physicians indicated that this is not happening; 85 percent report that PA interferes with continuity of care.
• Accelerate use of automation in PA processing. Despite health plan commitment to utilization of standard electronic transactions for PA, physicians report that phone and fax are still the most common methods for completing PAs. Additionally, only 21% of physicians report that their electronic health record system offers electronic PA for prescription medications, despite an existing standard process.

The AMA, however, noted that there has been progress in removing delays in treating opioid-use disorder.

While the AMA is pushing for state legislation that reforms PA, it has been pointed out that a Government Accountability Office report in 2017 concluded that prior authorization in Medicare saved as much as $1.9 billion that year. In addition, the Trump administration’s proposed budget includes expanded prior authorization measures for Medicare. Supporters of the process say it is helps control healthcare costs.