1 in 3 doctors reports serious adverse events due to Prior Authorization

A new survey by the American Medical Association (AMA) reveals the harmful effects of prior authorization on patients and physicians. The survey, conducted in December 2023, involved 1,001 physicians from various specialties and practice settings.

One-third of physicians report serious adverse events

According to the survey, one-third of the physicians reported that prior authorization has led to a serious adverse event for a patient in their care. These events include hospitalization, life-threatening situations, disability, or death. For example, 19% of the physicians said that prior authorization caused a delay or denial of care that required intervention to prevent permanent impairment or damage to a patient.

Unnecessary waste and delays

The survey also shows that prior authorization does not achieve its intended goals of cost and quality control. Instead, it leads to greater use of health care resources and unnecessary waste. About 86% of the physicians said that prior authorization resulted in more health care spending, rather than savings. More specifically, about two-thirds of the physicians said that prior authorization forced them to prescribe ineffective initial treatments (64%) or schedule additional office visits (62%) for their patients. Nearly half of the physicians (46%) said that prior authorization led to urgent or emergency care for patients.

Moreover, prior authorization causes significant delays in accessing necessary care. A staggering 94% of the physicians said that prior authorization delayed care for their patients. As a result, 89% of the physicians said that prior authorization negatively impacted patient clinical outcomes. Many patients also abandoned their treatment due to prior authorization hurdles. About 80% of the physicians said that they had patients who gave up on their prescribed treatment because of prior authorization.

Prior authorization criteria lack transparency and evidence

The survey also raises questions about the validity and transparency of the prior authorization criteria used by health insurers. Only 15% of the physicians said that prior authorization criteria were often or always evidence-based. Most of the physicians (85%) said that they were not aware of the clinical rationale behind the prior authorization decisions made by health insurers.

Imposes high administrative burden

The survey also highlights the high administrative burden associated with prior authorization. The physicians reported that they completed an average of 45 prior authorizations per week, which took up 14 hours of their time and staff time. To cope with this workload, 35% of the physicians said that they hired staff members who worked exclusively on prior authorization tasks.

AMA calls for reform

The AMA president, Dr. Jack Resneck Jr., called for reform of the prior authorization system, saying that it conflicts with evidence-based clinical practices, wastes vital resources, jeopardizes quality care, and harms patients. He said that the AMA is working with federal and state officials on legislative solutions to reduce waste, improve efficiency, and protect patients from obstacles to medically necessary care.

The AMA has also developed a set of principles and a toolkit to help physicians advocate for prior authorization reform. The AMA urges health insurers to adopt these principles and streamline their prior authorization processes.