Lack of Prior Authorization Reform Escalating Physician Burden

Prior authorization continues to increase administrative burden for physicians and impede continuity of patient care as health plans are not following their commitment to advance prior authorization reform, a study from the American Medical Association (AMA) found.

In January 2018, AMA, the American Hospital Association (AHA), AHIP, American Pharmacists Association (APhA), Blue Cross Blue Shield Association (BCBSA), and Medical Group Management Association (MGMA) signed a consensus statement agreeing to improve prior authorization processes.

The statement outlined five prior authorization reforms that promote safe, timely, and affordable access to evidence-based care for patients. Reforms also endorsed enhanced efficiency and reduced administrative burdens.

However, a recent AMA survey reflecting responses from more than 1,000 practicing physicians revealed that health plans are falling short of effective prior authorization reform.

“Waiting on a health plan to authorize necessary medical treatment is too often a hazard to patient health,” Gerald E. Harmon, MD, president of AMA, said in a press release. “Authorization controls that do not prioritize patient access to timely, optimal care can lead to serious adverse consequences for waiting patients, such as a hospitalization, disability, or death. Comprehensive reform is needed now to stem the heavy toll that continues to mount without effective action.”

One reform included in the consensus statement was to selectively implement prior authorization requirements based on a provider’s adherence to evidence-based guidelines and quality measures.

The survey found that only 9 percent of physicians reported contracting with health plans that offer programs that selectively apply prior authorization requirements. Meanwhile, 62 percent of physicians said that none of the health plans they contract with exempt physicians from prior authorization requirements.

The organizations also agreed to regularly review prior authorization requirements and remove items with low variation in utilization or low prior authorization denial rates to limit the volume of requirements. But 84 percent of physicians reported that the number of drugs and medical services requiring prior authorization has increased during the last five years.

Additionally, more than half of physicians reported that it was difficult to determine if a drug (65 percent) or medical service (62 percent) required prior authorization. This suggests that reform in the consensus statement calling for transparency and easy accessibility of prior authorization requirements, criteria, and program changes has been unsuccessful.

Prior authorization continues to disrupt patient care, physicians reported. Health plans agreed to encourage protections for continuity of care and minimize stalling needed treatment due to prior authorization requirements. However, 88 percent of physicians said that prior authorization interfered with continuity of care sometimes, often, or always.

Prior authorization automation is also lacking, despite healthcare organizations committing to accelerate the use of national standard transactions for electronic prior authorizations. Nearly 60 percent of physicians reported using a phone for completing prior authorizations. In contrast, only 26 percent said their EHR system offered electronic prior authorization for prescription medications.

“Given the health insurance industry’s lack of progress toward voluntarily expediting comprehensive prior authorization reform outlined in the consensus statement, the AMA and other physician organizations are calling on Congress to remedy the problem,” the press release stated.

AMA urged leaders to pass the Improving Seniors’ Timely Access to Care Act, which would codify most of the reforms included in the consensus statement and help relieve the burden of prior authorization.

According to MGMA’s 2021 Annual Regulatory Burden Report, prior authorization requirements were the top burden for medical groups, ranking higher than the Quality Payment Program and COVID-19 workplace mandates.