A recent physician survey found that the prior authorization process exceeds the benefit of the process to patients, according to a physician survey conducted by the American Medical Association. According to the survey, while health insurers say that prior authorization requirements are necessary for cost and quality control, physicians say that prior authorization controls lead to unnecessary waste and avoidable patient harm.
The survey found that 86% of physicians reported that prior authorization requirements led to higher overall utilization of health care resources. This includes the 64% of physicians who reported resources being diverted to ineffective initial treatments, 62% of physicians who reported additional office visits because of prior authorization policies, and 46% of physicians who reported prior authorization policies led to either urgent care or emergency care for patients.
Additionally, one-third of physicians reported that prior authorization practices led to a serious adverse event for one of their patients, including hospitalization, permanent impairment, or even death. Additionally, 94% of physicians reported prior authorization practices delaying access to necessary care (with 42% saying it often causes delay to necessary care) and 80% of physicians reported that patients had abandoned a course of treatment due to prior authorization struggles. The survey also found that 58% of physicians reported that prior authorizations impacted a patient’s ability to perform their job, resulting in lost workforce productivity.
While health insurance industry believes that prior authorization criteria reflects evidence-based medicine, physician experiences question that principle as only 15% of physicians reported that prior authorization criteria were always or often evidence based. 31% of physicians reported that prior authorization criteria were rarely or never evidence-based.
Not only did the survey find that prior authorizations had a negative overall impact on patient health, but 88% of physicians said that burdens associated with prior authorizations were either high or extremely high. The administrative burden associated with prior authorizations costs medical practices an average of 14 hours of physician and staff time each week. More than one-third of physicians had members of their staff that were exclusively working on tasks associated with prior authorizations.
“Health plans continue to inappropriately impose bureaucratic prior authorization policies that conflict with evidence-based clinical practices, waste vital resources, jeopardize quality care, and harm patients,” said AMA President Jack Resneck Jr., M.D. “The byzantine system of authorization controls is rife with opportunities for reform and the AMA continues to work with federal and state officials on legislative solutions to reduce waste, improve efficiency, and protect patients from obstacles to medically necessary care.”
AMA Also Submitted Comments to CMS Regarding Prior Authorization Reform
The AMA used the findings from this report to boost comments submitted to the Centers for Medicare and Medicaid Services (CMS) in support of CMS’ proposals to improve prior authorization across federal and state insurance programs. The AMA’s comments referenced the AMA Recovery Plan for America’s Physicians, with which one of the main five pillars is fixing prior authorization to reduce the burden on physician practices and minimize dangerous care delays for patients. While the AMA supports the agency’s efforts to reform prior authorization, the comments also included recommendations to strengthen the proposals, including comments around payer transparency and processing time requirements.
MGMA also submitted comments in response to those proposed rules, also taking the opportunity to make suggestions to the agency on how prior authorization could be reformed to help patients. Some of the suggestions in the MGMA comments included eliminating step therapy and shortening the time frame that health plans have to respond to medical groups for prior authorization requests.