The Medical Association recently joined the American Medical Association and 85 other national medical groups and state medical associations in sending a letter to the Centers for Medicare & Medicaid Services to urge CMS to provide guidance to Medicare Advantage plans on prior authorization processes through its 2020 Call Letter. In the jointly signed letter, the groups call upon CMS to require MA plans to selectively apply PA requirements and provide examples of criteria to be used for programs such as ordering/prescribing patterns that align with evidence-based guidelines and historically high PA approval rates. Citing the CMS Patients Over Paperwork initiative, the letter stresses this new guidance will promote safe, timely and affordable access to care for patients; enhance efficiency; and reduce administrative burden on physician practices.
The letter further explains how the prior authorization process has been found to be burdensome for health care providers, health plans and even patients and that physicians and insurers have agreed that these policy changes to eliminate PAs on those services for which there is low variation in care can promote greater transparency regarding services subject to PAs and protect patients to ensure PAs do not impact the continuity of care.
PA programs can create significant treatment barriers by delaying the start or continuation of necessary treatment, which may in turn adversely affect patient health outcomes. According to a 2018 AMA survey of 1,000 practicing physicians, 91 percent of physicians said PAs can delay a patient’s access to necessary care. These delays may have serious implications for patients and their health, as 75 percent of physicians reported that PA can lead to treatment abandonment, and 91 percent indicated that PA can have a negative impact on patient clinical outcomes. Most alarmingly, 28 percent of physicians indicated that PA has led to a serious adverse event (e.g., death, hospitalization, disability/permanent bodily damage) for a patient in their care.