Thirty percent of physicians reported that prior authorization requirements have led to a serious adverse event for a patient in their care, according to a new survey by the American Medical Association (AMA).
“As the COVID-19 pandemic began in early 2020, some commercial health insurers temporarily relaxed prior authorization requirements to reduce administrative burdens and support rapid patient access to needed drugs, tests and treatments,” said AMA President Susan R. Bailey, M.D., in a statement “By the end of 2020, as the U.S. health system was strained with record numbers of new COVID-19 cases per week, the AMA found that most physicians were facing strict authorization hurdles that delayed patients’ access to needed care.” According to the AMA survey, almost 70 percent of 1,000 practicing physicians surveyed in December 2020 reported that health insurers had either reverted to past prior authorizations policies or never relaxed these policies in the first place. More than nine in 10 physicians (94 percent) reported care delays while waiting for health insurers to authorize necessary care, and nearly four in five physicians (79 percent) said patients abandon treatment due to authorization struggles with health insurers.
While the health insurance industry says prior authorization criteria reflect evidence-based medicine, the AMA says that physician experience casts doubt on the credibility of this claim. Only 15 percent of physicians reported that prior authorization criteria were often or always based on evidence-based medicine. Specifically, the AMA said that prior authorization requirements led to the following repercussions for patients:
• Patient hospitalization – reported by 21 percent of physicians;
• Life-threatening event or intervention to prevent permanent impairment or damage – reported by 18 percent of physicians; and
• Disability or permanent bodily damage, congenital anomaly, birth defect, or death – reported by 9 percent of physicians
“Delayed and disrupted treatment due to an archaic prior authorization process can have life-or-death consequences for patients, especially during a public health emergency,” added Bailey. “This hard-learned lesson from the current crisis must guide a re-examination of administrative burdens imposed by health insurers, often without any justification.”
Other physician concerns highlighted in the AMA survey include:
• Nine in 10 physicians (90 percent) reported that prior authorizations programs have a negative impact on patient clinical outcomes.
• A significant majority of physicians (85 percent) said the burdens associated with prior authorization were high or extremely high.
• Medical practices complete an average of 40 prior authorizations per physician, per week, which consume the equivalent of two business days (16 hours) of physician and staff time.
• To keep up with the administrative burden, two out of five physicians (40 percent) employ staff members who work exclusively on tasks associated with prior authorization.
Insurers have put an emphasis on improving electronic processes for prior authorization to make it less burdensome. A recent analysis, spearheaded by America’s Health Insurance Plans (AHIP), revealed that electronic prior authorization (ePA) can significantly reduce the time between a request for prior authorization and a decision, as well as the time to a patient receiving care.
AHIP launched its Fast Prior Authorization Technology Highway—or Fast PATH— initiative to better understand how electronic prior authorization could impact the process for patients and providers. Six health insurance providers—Blue Shield of California, Cambia Health Solutions, Cigna, Florida Blue, Humana, and WellCare (now Centene)—that collectively cover over 50 million Americans participated in the project, with Availity and Surescripts serving as the technology partners.
The ePA approach allows physicians and their staffs to request approval from pharmacy benefit managers (PBMs) and health plans inside their electronic health records (EHRs). Across the industry, most EHRs, health systems, payers and pharmacies have committed to electronic prior authorization.
The AHIP initiative began in early 2020 and ran for approximately 12 months. RTI International conducted an independent evaluation of the project, with Point of Care Partners serving as an expert advisor to the project. The evaluation included analyzing prior authorization transaction data before and after implementation of ePA, and surveying providers on their experiences using ePA technology, according to officials who released a press release on the findings this week.
The study found that 71 percent of experienced providers who implemented ePA reported faster time to patient care. In addition, ePA reduced the time between submitting a prior authorization request and receiving a decision from the health plan by 69 percent; the median time from prior authorization request to decision fell from 18.7 hours to 5.7 hours.
