AMA: Prior Authorizations “Apathetic and Ineffectual”

“Apathetic”. “Ineffectual”. Those were the findings from a recent physician survey by the American Medical Association (AMA) regarding so-called reforms to the system of prior insurance authorizations.

Prior authorization, as we know, is the practice of asking and, hopefully, receiving payment authorization prior to service delivery (medication, treatment, or procedure). Each health plan has its own rules for prior authorizations. It’s an issue.

In January 2018, the AMA along with the American Hospital Association, America’s Health Insurance Plans, the American Pharmacists Association, the Blue Cross Blue Shield Association, and the Medical Group Management Association released the “Consensus Statement on Improving the Prior Authorization Process.” The Consensus Statement recommended five key reforms that, according to a recent AMA press release, “promote safe, timely, and affordable access to evidence-based care for patients; enhanced efficiency; and reduced administrative burdens.”

The five key reforms were:

1. selective application of prior authorization requirements;
2. adjustment of the volume of prior authorization;
3. prior authorization transparency;
4. continuity of patient care; and
5. improved automation.

According to the December 2021 AMA survey of more than 1,000 practicing physicians, the five key reforms have yet to be implemented.

Key findings from the AMA physician survey were:

• Only 9% of physicians report contracting with health plans that offer programs that exempt providers from PA [prior authorization].”
• Prior authorizations are increasing. 84% of physicians report that the number of prior authorizations “required for prescription medications and medical services has increased over the last five years.”
• No transparency. A majority of physicians surveyed agreed with the statement that it is “difficult to determine whether a prescription medication or medical service requires prior authorization.”
• 88% of physicians report that prior authorization “interferes with continuity of care.”
• Only about a quarter (26%) of physicians report that they could use their electronic health records system for electronic prior authorization for prescription medications.

AMA President Gerald E. Harmon, M.D. commented, “Waiting on a health plan to authorize necessary medical treatment is too often a hazard to patient health.”

Dr. Harmon continued, “Authorization controls that do not prioritize patient access to timely, optimal care can lead to serious adverse consequences for waiting patients, such as a hospitalization, disability, or death. Comprehensive reform is needed now to stem the heavy toll that continues to mount without effective action.”

The AMA is urging reform through public involvement and legislative action. In the AMA press release, it promotes the Improving Seniors’ Timely Access to Care Act which would put into law much of the Consensus Statement.