Prior Authorization Challenges Persist, AMA Survey Reveals

A recent survey from the American Medical Association (AMA) evaluated the challenges and roadblocks of prior authorization (PA) for physicians and patients three years after a coalition of industry groups led by AMA released a consensus statement agreeing on necessary PA reforms to ease burdens, significant challenges still persist.

The other groups in the coalition included the American Hospital Association (AHA), America’s Health Insurance Plans (AHIP), American Pharmacist Association, Blue Cross Blue Shield Association, and Medical Group Management Association (MGMA).

“Prior authorization remains a major obstacle to achieving optimal patient care,” said Susan Bailey, president of (AMA), in a recent press release. 

The consensus statement from 2018 outlined five key areas of reform regarding prior authorization: selective application of prior authorization, transparency and communication, continuity of care, program review and volume adjustment, and automation to improve efficiency.

In terms of the selective application of prior authorization, the survey states that the consensus statement agreement was to “encourage the use of programs that selectively implement PA requirements based on stratification of health care providers’ performance and adherence to evidence-based medicine.”

Survey results, collected in December 2020, revealed that only 11 percent of physicians reported contracting with health plans that offer exemptions from prior authorization. 

About 68 percent of physicians reported that it is challenging to determine whether a prescription medication requires prior authorization, and 58 percent reported that it is challenging to determine whether a medical service requires prior authorization. 

This result does not align with the agreements made in the consensus statement, which aimed to “encourage transparency and easy accessibility of prior authorization requirements, criteria, rationale, and program changes to contracted health care providers and patients/enrollees.”

A majority of responding physicians (87 percent) reported that prior authorization interferes with continuity of care. Roadblocks with prior authorization can lead to delays in critical procedures and can extend the time patients have to wait to receive necessary prescriptions.

The consensus statement encouraged significant revisions to prior authorization requirements aimed at reducing the list of procedures and medications that require it. However, 83 percent of physicians reported that the number of prior authorizations required has increased over the past five years. 

Many of the administrative burdens associated with prior authorization have to do with out-of-date systems that slow the process. Physicians reported that phone and fax were still the most common communication methods for prior authorization in 2020. Only 24 percent of physicians reported that their EHR system could accommodate prior authorization transactions for medications, the survey said. 

A recent study revealed that electronic prior authorizations may in fact decrease administrative burdens and improve patient experience and the overall quality of care. Meanwhile, another 2020 AMA survey found that on average, practices completed 40 prior authorizations per physician each week, consuming two full business days of administrative work.

Partly due to inaction by the insurance industry after the consensus statement was released, physicians, lawmakers, and major health organizations are now calling for additional prior authorization reform through the introduction of the Improving Seniors’ Timely Access to Care Act of 2021. Under this legislation, Medicare Advantage (MA) plans would be required to establish a simplified electronic prior authorization process, as well as regularly reporting to CMS on their use of prior authorization. 

“When seniors need critical medical care, doctors and other health care providers should be spending their time working with patients instead of going back and forth on requests that should be electronic, standardized, and eventually automated,” said Congresswoman Suzan Delbene (WA-01), one of the representatives who introduced the bill, in a press release. 

The bipartisan bill aims to combat this issue by modernizing the system with the adoption of electronic prior authorization transactions. The bill would also require HHS to develop a system that provides real-time decisions to expedite routine prior authorization requests, diminishing the waiting period. In order to ensure transparency and accountability, the bill also proposes that MA plans meet certain beneficiary protection standards and are closely monitored by CMS. 

“There is no room in the patient-physician relationship for insurance-industry barriers,” said Bailey. “This legislation is a win-win for patients and physicians.”