Prior Authorization Process Continues to Weigh On Providers and Patients, AMA Says

An American Medical Association (AMA) survey of 1000 physicians regarding the impact of prior authorization (PA) found that most providers reported a significant or negative impact on patient care, and more than a quarter reported a serious adverse event (AE).

Serious AEs—death, hospitalization, disability, permanent body damage, or other life-threatening complication—were reported by 28% of respondents, and more than 9 in 10 respondents said PA had a significant or somewhat negative clinical impact.

The web-based survey was conducted in December 2018 and was answered by specialists (60%) and primary care physicians (40%).

The use of PAs has long been a concern of the AMA; according to the organization, utilization management programs—including PAs and step therapy—can create significant barriers for patient-centered care, as the manual, time-consuming processes often used in these programs place additional burdens on providers and direct resources away from patient care.

In the 2018 survey, doctors said that they or their staff spent 2 working days each week completing PAs, and 36% have staff whose sole job is to work on PAs. On average, practices complete 31 PAs per provider per week.

Not surprisingly, 86% of physicians reported that PAs created a high or extremely high burden for the office. In addition, 88% said the burden has increased over the last 5 years.

Other findings of the survey include:

• Most providers wait between 1-5 days for a decision from health plans about the status of their PA request.
• Care delays are common, with 47% reporting that necessary care was delayed “always” or “often,” and 44% finding that care was “sometimes” delayed.
• Abandoned treatment is also common, with 22% saying issues related to the PA process “always” or “often” led to patients not following treatment plans, while 53% said this “sometimes” happened.
• Most providers (91%) had a negative perception of the impact of PA on clinical outcomes.

The AMA noted that, traditionally, insurers applied PA to newer, more expensive services and medications. But in recent years, physicians have reported an increase in the volume of PAs.

For instance, at a 2017 annual meeting of the American College of Rheumatology, clinicians noted that PAs were increasing not only for expensive biologics to treat rheumatic diseases, but also for older, less-expensive medications such as steroid therapies or methotrexate. One presenter said the increasing volume of specialty drug prescriptions, steeper renewal requirements, insurance expansion, new therapeutics, and formulary updates were all factors behind the increased volume.

“The AMA survey continues to illustrate that poorly designed, opaque (PA) programs can pose an unreasonable and costly administrative obstacle to patient-centered care,” said AMA Board of Trustees Chair Jack Resneck Jr., MD, in a statement.