AMA Survey: Patient Clinical Outcomes Shortchanged by Prior Authorization

New collaborative opportunities underway to create change

More than nine in 10 physicians (92%) say that prior authorizations programs have a negative impact on patient clinical outcomes, according to a new physician survey released by the American Medical Association (AMA). The survey results further bolster a growing recognition across the entire health sector that prior authorization programs must be reformed.

“Under prior authorization programs, health insurance companies make it harder to prescribe an increasing number of medications or medical services until the treating doctor has submitted documentation justifying the recommended treatment,” said AMA Chair-elect Jack Resneck Jr., MD, in a press statement. “In practice, insurers eventually authorize most requests, but the process can be a lengthy administrative nightmare of recurring paperwork, multiple phone calls, and bureaucratic battles that can delay or disrupt a patient’s access to vital care. In my own practice, insurers are now requiring prior authorization even for generic medications, which has exponentially increased the daily paperwork burden.”

According to the AMA survey, which examined the experiences of 1,000 patient care physicians, nearly two-thirds (64%) report waiting at least one business day for prior authorization decisions from insurers—and nearly one-third (30%) said they wait three business days or longer.

The high wait times for preauthorized medical care have consequences for patients. More than nine in 10 physicians (92%) said that the prior authorization process delays patient access to necessary care; and nearly four in five physicians (78%) report that prior authorization can sometimes, often, or always lead to patients abandoning a recommended course of treatment.

In addition, a significant majority of physicians (84%) said the burdens associated with prior authorization were high or extremely high, and a vast majority of physicians (86%) believe burdens associated with prior authorization have increased during the past five years.

The survey findings show that every week a medical practice completes an average of 29.1 prior authorization requirements per physician, which takes an average of 14.6 hours to process—the equivalent of nearly two business days. To keep up with the administrative burden, about one-third of physicians (34%) rely on staff members who work exclusively on the data entry and other manual tasks associated with prior authorization.

“The AMA survey illustrates a critical need to help patients have access to safe, timely, and affordable care, while reducing administrative burdens that take resources away from patient care,” Dr. Resneck said. “In response, the AMA has taken a leading role in convening organizations representing pharmacists, medical groups, hospitals, and health insurers to take positive collaborative steps aimed at improving prior authorization processes for patients’ medical treatments.”

In January 2017, the AMA with 16 other associations urged an industry-wide reassessment of prior authorization programs to align with a newly created set of 21 principles intended to ensure that patients receive timely and medically necessary care and medications and reduce the administrative burdens. More than 100 other health care organizations have supported those principles.

In January 2018, the AMA joined the American Hospital Association, America’s Health Insurance Plans, American Pharmacists Association, Blue Cross Blue Shield Association, and Medical Group Management Association in a consensus statement outlining a shared commitment to industry-wide improvements to prior authorization processes and patient-centered care.

Earlier this month, the AMA and Anthem announced a collaboration that would include, among other goals, identifying opportunities to streamline or eliminate low-value prior-authorization requirements and implementing policies to minimize delays or disruptions in the continuity of care.

Source: AMA; March 20, 2018.

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