Physicians Call for Prior Authorization Reform

The Medical Association has joined a coalition of physicians’ groups, hospitals, medical groups, pharmacists and other health care organizations to urge health plans, benefit managers and other groups to reform prior authorization requirements imposed on medical tests, procedures, devices and medications. The coalition is responding to what has been deemed unreasonable hurdles for patients seeking care and argue that requiring pre-approval by insurers before certain treatments can delay or interrupt medical services, divert significant resources from patient care and complicate medical decisions.

Given the potential barriers prior authorizations can pose to patient-centered care, the coalition is urging an industry-wide reassessment of these programs to align with a newly created set of 21 principles. Prior authorization programs could be improved by applying the principles’ common-sense concepts grouped in five broad categories:

• Clinical validity,
• Continuity of care,
• Transparency and fairness,
• Timely access and administrative efficiency, and
• Alternatives and exemptions.

“Strict or bureaucratic oversight programs for drug or medical treatments have delayed access to necessary care, wasted limited health care resources and antagonized patients and physicians alike,” said AMA President Andrew W. Gurman, M.D. “The AMA joins the other coalition organizations in urging health insurers and others to apply the reform principles and streamline requirements, lengthy assessments and inconsistent rules in current prior authorization programs.”

The data entry and administrative tasks associated with prior authorization reduce time available for patients. According to a new AMA survey, every week a medical practice completes an average of 37 prior authorization requirements per physician, which takes a physician and their staff an average of 16 hours, or the equivalent of two business days, to process.

The AMA survey illustrates that physician concerns with the undue burdens of preauthorizing medical care have reached a critical level. Highlights from the AMA survey include:

• Seventy-five percent of surveyed physicians described prior authorization burdens as high or extremely high.
• More than a third of surveyed physicians reported having staff who work exclusively on prior authorization.
• Nearly 60 percent of surveyed physicians reported that their practices wait, on average, at least one business day for prior authorization decisions—and  more than 25 percent of physicians said they wait 3 business days or longer.
• Nearly 90 percent of surveyed physicians reported that prior authorization sometimes, often, or always delays access to care.

For specialists like Montgomery oncologist Stephen Davidson, M.D., at the Montgomery Cancer Center, issues with PAs can begin when the patient checks in for the first appointment.

“There are days when I have patients who are scheduled to see me as new patients. They are at the front door. They have something that brought them here that has also emotionally disturbed them greatly. If their PA is not in place, they can’t so much as walk down the hall to see me,” Dr. Davidson said. “This happens…constantly.”

Dr. Davidson and his team see an average of 60 patients each day. During that time, he and his treatment team are also securing PAs for patients for imaging and medicine. Rarely are cancer medications generic, making them very expensive, so PAs must be secured for monthly refills, taking even more time away from patient care.

“It has become a tremendous burden,” Dr. Davidson said. “Somewhere along the way the burden of proof shifted from the insurance company to the physician. Traditionally there has been a respect for a physician’s judgment and decision making on behalf of the patient. That’s a very special and sacred relationship. Now, because of a number of factors, primarily economic, we have insurance companies that don’t respect the physician’s authority in the decision-making process.”

Read more about what Dr. Davidson and Lee Carter, M.D., of Autaugaville had to say about PAs in our article from Alabama Medicine magazine, Between Doctors & Physicians: Prior Authorizations.