Waiting for prior authorization decisions for some medical care is not only irksome but can be dangerous to patients. Health plans are loosening the reins a bit.
With a strong push from the American Medical Association (AMA), health plans are beginning to relax the prior authorization requirements that have long frustrated consumers. Physicians are united in their concerns that prior authorization can threaten patient care, so insurers are relenting and relying more on doctors' good judgment.
A recent AMA survey found that 92% of physicians say prior authorization programs have a significant (61%) or somewhat (31%) negative impact on patient clinical outcomes. Pre-authorizations have vexed consumers and physicians alike for decades, but the problem has gotten worse in recent years, says AMA Chair-elect Jack Resneck Jr., MD.
"This is a tremendous burden that's taking up a lot of time that we could be spending with patients. But it's not just a burden for us. It's also detrimental to our patients," Resneck says. "In my own practice, it's not just the brand-new, expensive drugs where we would expect to have prior authorization. It's happening for even the generic, inexpensive drugs. It's not always clear it will require a pre-authorization until the patient gets to the pharmacy, and then that can result in several days delay in care."
Some patients even have to go through prior authorization multiple times for the same medication when they try to refill a prescription, Resneck says. The patient may have changed health plans, or the medication protocols within the same health plan might have been updated.
Insurers eventually authorize most requests, Resneck says, but that does not diminish the impact of the required paperwork, phone calls, negotiations, and the delay in a patient's care.
The AMA survey examined the experiences of 1,000 patient care physicians, and 64% of physicians report waiting at least one business day for prior authorization decisions from insurers. Thirty percent said they wait three business days or longer.
In addition to 92% of physicians who said that the prior authorization process always (15%), often (39%), or sometimes (38%) delays patient access to necessary care, 78% said prior authorization can always (2%), often (19%), or sometimes (57%) lead to patients abandoning a recommended course of treatment.
Two days per week for authorizations
Eighty-four percent of physicians surveyed said the burdens associated with prior authorization were high or extremely high, and 86% percent said the burdens associated with prior authorization have increased significantly (51%) or increased somewhat (35%) during the past five years.
A medical practice completes an average of 29.1 average total prior authorization requirements per physician every week, which takes an average of 14.6 hours to process—the equivalent of nearly two business days, the survey found. The administrative burden is so high that 34% of physicians said they rely on staff members who work exclusively on the data entry and other manual tasks associated with prior authorization.
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.
AMA and Anthem recently announced a collaboration to improve access to care that includes eliminating low-value prior authorization requirements. The AMA has been working with several health plans to address the problem.
"There are some medications and tests the insurer ends up approving the majority of the time, so doctors are spending a lot of time filling out paperwork and on the phone, and the health plan on the other end is spending a lot of time reading that paperwork and answering our requests," Resneck says. "One of the things we agreed to was eliminating some of those things from the pre-authorization list that were creating an administrative burden for everyone but for little or no benefit to the insurer."
Health plans also are agreeing to give physicians the benefit of the doubt in more situations, particularly those with good track records of making the right clinical decisions.
"We're trying to come up with a system in which health plans can have sort of a gold card for physicians that acknowledges they have been shown to practice evidence-based medicine and the insurer almost always approves the requested care," Resneck says.
"Then the insurer could waive a lot of the prior authorization requirements for that physician without any adverse results. The insurer still can be confident that the care is appropriate, but they and the physician are both spared the hassle and the patient gets the proper care without delay," he says.
State legislatures have shown some interest in limiting prior authorizations, Resneck says, but the AMA is focusing now on working directly with insurers.
"The legislative remedies for patient protection and access to medications may be a piece of the puzzle, but we are trying to start with a collaborative approach and finding areas of agreement with health plans," he says.
Gregory A. Freeman is a contributing writer for HealthLeaders.