The ACR was part of a 16-member collaboration that created a set of 21 principles on prior authorization and utilization management, intended to ensure that patients receive timely and medically necessary care and medications and reduce the administrative burdens. More than 100 other healthcare organizations support those principles. Now, the AMA has released the results of a new physician survey highlighting the significant negative consequences prior authorization (PA) has on patient access to care and treatment. Example: Medical practices complete an average of 29.1 PA requirements per physician per week, which takes an average of 14.6 hours to process—the equivalent of nearly two business days.
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Negative Impact on Timely Care
Anecdotes about the patient care delays and practice burdens caused by health plans’ onerous prior authorization (PA) requirements are common, but quantitative data to substantiate these stories have been limited until recently. Results from the new PA survey provide strong evidence of the significant impact this burdensome process can have on patients and physician practices. Results from the survey of 1,000 practicing physicians clearly show the negative effect that PA can have on timely patient care. Among surveyed physicians, 64% reported waiting at least one day for PA decisions from health plans, and 30% reported waiting at least three business days.
These wait times translate into patient care delays, with 92% of physicians saying that PA sometimes, often or always delays access to necessary care. These delays may have more serious implications for patients; 78% of physicians reported that PAs can lead to treatment abandonment. Moreover, an overwhelming majority (92%) of physicians indicated that PAs can have a negative impact on clinical outcomes.
The survey also addressed the burdens imposed on physicians and their staff by PAs. The survey results show that practices complete an average of 29.1 PAs per week per physician, with this PA workload requiring 14.6 hours—nearly two business days—of physician and staff time. Not surprisingly, 84% of physicians characterized PA-related burdens as high or extremely high. PA hassles have also been growing over time, with 86% of physicians reporting that PA burdens have increased over the past five years.
These data reinforce the need for strong advocacy efforts on PA reform. The AMA has undertaken a major campaign to urge health plans to right-size PA programs. In January 2017, the AMA, the ACR and a coalition of 16 other organizations representing physicians, hospitals, medical groups, pharmacists and patients released a set of 21 Prior Authorization and Utilization Management Reform Principles. These principles, which have been formally supported by more than 100 additional provider and patient groups, spurred conversations with health plans about the need for significant reform in PA programs.
As a result of those discussions, the AMA, along with the American Hospital Association, America’s Health Insurance Plans, American Pharmacists Association, Blue Cross Blue Shield Association and Medical Group Management Association, released the Consensus Statement on Improving the Prior Authorization Process in January 2018. This document reflects agreement between provider and health plan organizations to pursue PA reform in several key areas, including reduction in the overall volume of PAs, improved transparency and communication, protection of continuity of care and automation to increase process efficiency.
State legislative efforts also play a critical role in the AMA’s campaign to improve PA processes, and the AMA is working with state and specialty societies to enact legislation. The AMA offers model legislation that continues to serve as the basis for many of the state bills and provides resources and support for these efforts. This year alone, more than 20 states are addressing utilization management reform in their legislatures. (See “Arkansas PBM Bill Offers Transparency.”)
At the federal level, the ACR, working with a coalition of other physician organizations, recently sent a letter to Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma. The letter discussed one of the top administrative burdens under Medicare—PA requirements of Medicare Advantage Organizations (MAOs). The signed organizations strongly believe that CMS guidance and oversight in this area are timely and necessary to reduce unnecessary administrative burdens and to maintain patient access to care. The ACR, along with coalition colleagues, has also met with the CMS on increased oversight and issuing guidance to MAO plans on the appropriate uses of PA. The ACR has been an active participant in meetings on Capitol Hill to educate Congress on the overuse of PAs by MAO plans.
The ACR is also working to advance the Standardizing Electronic Prior Authorization for Safe Prescribing Act of 2018 (H.R. 4841), which would streamline and reduce delays for prior authorization approval in Medicare by requiring the CMS to provide for the development of an electronic prior authorization (ePA) standard for Part D and Medicare Advantage plans.
We encourage you to use the PA survey results in your advocacy efforts on this important issue. The survey results, along with a variety of other PA advocacy and educational resources, are available at ama-assn.org/prior-auth. If you have an ongoing prior authorization issue on which you would like the ACR to assist, write to firstname.lastname@example.org.