Nearly 100 Healthcare Associations and Medical Societies Urge CMS to Rethink Prior Authorization Issues for Physicians

Sept. 28, 2019
On September 20, the AMA and 98 other healthcare associations and medical societies wrote a letter to Seema Verma at CMS, urging her to rethink issues around prior authorization for physicians

On September 20, the Chicago-based American Medical Association (AMA) and 98 other healthcare associations and medical societies wrote a letter to Seema Verma, Administrator of the federal Centers for Medicare and Medicaid Services (CMS), asking her to rethink issues around prior authorization for physicians.

In a press release published to its website on Sep. 25, the AMA stated that “Physicians across the country and across specialties are urging the Centers for Medicare & Medicaid Services (CMS) to reduce the harms and burdens of prior authorization by incorporating Consensus Principles into its policies and encouraging other payers to do so as well. The Consensus Principles were developed by national provider associations and insurer trade organizations. The letter, led by the American Medical Association (AMA) and signed by 104 other medical societies, thanks CMS for tackling prior authorization through its Patients Over Paperwork initiative. CMS Administrator Seema Verma has acknowledged publicly that prior authorization interferes with and delays treatment, and contributes to physician burnout.”

Further, the press release notes that “[I]ndustry focus on only the technological aspects of prior authorization will not solve the problem and, in fact, could set the stage for increased use of prior authorization. The AMA and other signatories are offering assistance to CMS in advancing the important reform goals incorporated in the Consensus Principles.”

The letter to Administrator Verma was co-signed by 98 healthcare associations and medical societies, including the AMA itself. The 98 organizations wrote that “The undersigned physician organizations support the Centers for Medicare & Medicaid Services’ (CMS) Patients Over Paperwork initiative and applaud CMS for tackling the challenging issue of prior authorization (PA) as part of your efforts to reduce administrative burdens in health care. Physician practices report completing an average of 31 PAs per physician per week. This workload consumes 14.9 hours (nearly 2 business days) each week of physician and staff time and reflects time that would be better spent with patients. More importantly, PA is negatively impacting patient care.”

As the 98 organizations noted, “Over one-quarter (28 percent) of physicians report that PA has led to a serious adverse event (e.g., disability, hospitalization, death) for a patient in their care. We do, however, have strong concerns that CMS may be focusing on automation as the only vehicle for implementing PA reforms. We are aware,” the associations said, “that CMS has invested heavily in the Da Vinci Project, which leverages technology to facilitate electronic exchange of clinical data by extracting information from physicians’ electronic health records (EHRs). While Da Vinci holds promise, there are a series of issues with exclusively relying on technology to address the burdens of PA. For example, solely concentrating on process automation may set the stage for increased PA volume because document exchange will be easier and faster. Patient care delays will continue, as manual review of medical documentation is often required following the instantaneous electronic exchange of data. Furthermore, Da Vinci will allow payers unprecedented access to EHRs. Protections are needed to prevent plans from inappropriately accessing patient information, coercing physicians into using technology (e.g., through contracts), or interfering with medical decision making. Lastly, Da Vinci represents nascent technologies that have yet to be widely implemented. Therefore, the costs and the timeframe availability across EHR vendors remain unclear. Of considerable concern, Da Vinci likely will not offer relief from PA for small practices in the near future.”

Importantly, the letter states, “Automation is important, but it reflects only one of five major reforms we believe are needed to address the significant problems caused by PA. While we understand there may be a role for PA, we believe it must be right-sized and used judiciously. We strongly urge CMS to implement a comprehensive strategy to reduce the harms and burdens of PA…”