STUDY: Prior Authorization Hurdles Have Led to Serious Adverse Events

FEB 5, 2019 CHICAGO — More than one-quarter of physicians surveyed, about 28 percent, report the prior authorization process required by health insurers for certain drugs, tests and treatments have led to serious or life-threatening events for their patients, according to new survey results released by the American Medical Association.

The AMA survey of 1,000 practicing physicians found that prior authorization continues to have a distressing impact on both patients and physician practices. Despite widespread calls for meaningful reform during the last two years, the survey illustrates that prior authorization programs and existing processes remain costly, inefficient, opaque, and hazardous in some cases.“The AMA survey continues to illustrate that poorly designed, opaque prior authorization programs can pose an unreasonable and costly administrative obstacle to patient-centered care,” said AMA Chair Jack Resneck, Jr., M.D. “The time is now for insurance companies to work with physicians, not against us, to improve and streamline the prior authorization process so that patients are ensured timely access to the evidence-based, quality health care they need.”

Critical physician concerns highlighted in the AMA survey include:

• More than nine in 10 physicians (91 percent) say that prior authorizations programs have a negative impact on patient clinical outcomes.

• Nearly two-thirds of physicians (65 percent) report waiting at least one business day for prior authorization decisions from insurers – and more than one-quarter (26 percent) said they wait three business days or longer.

• More than nine in 10 physicians (91 percent) said that the prior authorization process delays patient access to necessary care, and three-quarters of physicians (75 percent) report that prior authorization can at least sometimes lead to patients abandoning a recommended course of treatment.

• A significant majority of physicians (86 percent) said the burdens associated with prior authorization were high or extremely high, and a clear majority of physicians (88 percent) believe burdens associated with prior authorization have increased during the past five years.

• Every week a medical practice completes an average of 31 prior authorization requirements per physician, which take the equivalent of nearly two business days (14.9 hours) of physician and staff time to complete.

• To keep up with the administrative burden, more than a third of physicians (36 percent) employ staff members who work exclusively on tasks associated with prior authorization.

“The AMA is committed to attacking the dysfunction in health care by removing the obstacles and burdens that interfere with patient care,” said Dr. Resneck. “To make the patient-physician relationship more valued than paperwork, the AMA has taken a leading role by creating collaborative solutions to right-size and streamline prior authorization and help patients access safe, timely, and affordable care, while reducing administrative burdens that pull physicians away from patient care.”

In January 2017, the AMA with 16 other associations urged industry-wide improvements in prior authorization programs to align with a newly created set of 21 principles intended to ensure that patients receive timely and medically necessary care and medications and reduce the administrative burdens. More than 100 other health care organizations have supported those principles.

In January 2018, the AMA joined the American Hospital Association, America’s Health Insurance Plans, American Pharmacists Association, Blue Cross Blue Shield Association and Medical Group Management Association in a Consensus Statement outlining a shared commitment to industry-wide improvements to prior authorization processes and patient-centered care.

The AMA welcomes the opportunity to work collaboratively with health plans and others to create a partnership that lays the foundation for a more transparent, efficient, fair, and appropriately targeted prior authorization process. Please visit the AMA website to learn more about the organization’s ongoing collaborative efforts.