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Prior authorizations harm patients and are costly to practices, doctors say


AMA president calls process “byzantine” and “ripe for reform”

A solid majority of the nation’s doctors think that payers’ prior authorization (PA) requirements are wasteful and worsen patient outcomes, according to results of a new survey.

The survey, conducted by the American Medical Association (AMA) asked 1,001 practicing physicians about how PAs affect their patients and practices. Among its findings:

  • 94% of respondents said that PAs delayed access to necessary care
  • 89% reported PAs having a “significant” or “somewhat” negative impact on patient clinical outcomes
  • 86% said the PA process leads to greater utilization of health care resources such as additional office and emergency department visits and hospitalizations
  • 80% said that in at least some cases disputes over PAs have caused patients to abandon treatment
  • 33% said that PA requirements have led to a serious adverse event such as a patient’s death or hospitalization

In addition, and contrary to insurance company claims, 31% of respondents said that PA requirements are “rarely” or “never” evidence based.

In an accompanying statement AMA President Jack Resneck Jr., M.D. called the PA process “byzantine” and “ripe for reform.”

“Health plans continue to inappropriately impose bureaucratic prior authorization policies that conflict with evidence-based clinical practices, waste vital resources, jeopardize quality care, and harm patients,” Resneck said.

Asked about the impact of PAs on their practice, 88% of respondents said they were “high” or “extremely high.” The survey also showed that practices complete an average of 45 PAs per physician per week, requiring 14 hours of physician and staff time. Thirty-five percent of doctors said they employed staff members whose sole responsibility was tasks associated with PAs.

The AMA said it has submitted comments to the Centers for Medicare & Medicaid Services (CMS) largely supporting the agency’s proposed rule, announced in December 2022, for improving the PA system. The Rule would require certain payers to implement an electronic PA process, shorten the time frames for certain payers to respond to PA requests, and establish policies to make the PA process more efficient and transparent.

The American Academy of Family Physicians (AAFP) has also endorsed the proposed rule but wants CMS to go even further. In a letter to Xavier Becerra, secretary of the Department of Health and Human Services, and CMS Administrator Chiquita Brooks-LaSure, the academy said automating the prior authorization process is just “one step in reducing the care delays and administrative burdens resulting from prior authorization.”

“Comprehensive reform and a reduction in the overall volume of prior authorization requests is necessary to see a meaningful reduction in the harmful impacts of prior authorization on patient care and physician wellbeing.” In particular, the academy wants the PA proposals extended to apply to prescription and outpatient drugs.

“Family physicians report that prior authorization requirements for medications are the most burdensome and excluding them from the required standards…will severely limit the impact this rule will have on improving patient care or reducing administrative burdens,” the letter says.

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