- July 30, 2024
- Posted by: Thomas Anderson
- Categories:
According to a survey conducted by the AMA among America’s physicians, over 90% report that prior authorization negatively impacts patient clinical outcomes.
Notably, 78% of physicians indicated that prior authorization often or sometimes leads to patients abandoning a recommended treatment course, as revealed in the AMA’s annual nationwide prior authorization survey of 1,000 practicing physicians.
In addition to patients forgoing care, physicians see prior authorization causing care delays and serious adverse events.
Among the surveyed physicians, these percentages reported that prior authorization:
- Always, often, or sometimes delays patients’ access to necessary care—94%.
- Resulted in a serious adverse event leading to a patient’s hospitalization—19%.
- Resulted in a serious adverse event causing a life-threatening situation or requiring intervention to prevent permanent impairment or damage—13%.
- Resulted in a serious adverse event leading to a patient’s disability, permanent bodily harm, congenital anomaly, birth defect, or death—7%.
Additionally, 53% of physicians with patients in the workforce said prior authorization affected their patients’ job performance.
“Physicians nationwide witness the dangerous, harmful, and sometimes deadly consequences of prior authorization,” wrote AMA President Bruce A. Scott, MD, in a Leadership Viewpoints column accompanying the survey’s release.
“Insurers create barriers supposedly to save money for the health system and conserve resources. However, when patients and their doctors encounter care delays—or even abandon necessary care—the results can increase overall costs as worsening health conditions force patients to seek urgent or emergency treatment. Our patients are caught in the middle, struggling while physicians fight for them, often with fax machines as our only available weapon.”
The AMA is addressing prior authorization issues by challenging insurance companies to eliminate care delays, patient harms, and practice hassles.
Beyond the patient toll, prior authorization also places a huge burden on physicians. The process detracts from the time they would spend with patients and necessitates hiring office staff specifically to handle the paperwork and appeals.
Physicians reported that:
- On average, their practices complete 43 prior authorizations per physician per week.
- They and their staff spend 12 hours weekly completing prior authorizations.
- Prior authorization somewhat or significantly increases physician burnout, with 95% of physicians feeling this way.
- Few peer-to-peer consultations involve a “peer” with the appropriate qualifications. Only 15% of physicians surveyed reported that they often or always speak to the appropriate peer.
The survey also revealed that prior authorization adds significant costs to the entire health care system. Among the physicians surveyed:
- 87% said prior authorization leads to higher overall health care utilization.
- 79% said prior authorization led to patients paying out of pocket for medication.
- 69% reported ineffective initial treatments, for instance, due to step-therapy requirements.
- 68% said prior authorization led to additional office visits.
- 42% reported immediate care or emergency department visits.
- 29% reported hospitalizations.
Addressing prior authorization in Medicare Advantage
Following some progress on the state and federal legislative fronts last year, Congress is set to take further action to improve prior authorization this year.
In June, bipartisan and bicameral legislation was reintroduced to streamline and standardize how Medicare Advantage uses prior authorization. The AMA supports this legislation, the Improving Seniors’ Timely Access to Care Act of 2024. This bill is an updated version of legislation that did not pass the Senate in the previous Congress.
In an AMA video on prior authorization, Dr. Scott said, “I want legislators to understand that this process wastes physicians’ time, wastes money, and more importantly, stresses patients. Patients and physicians work together to develop a plan and know what is best for them. Insurance companies should not insert themselves into that relationship.”
At its Annual Meeting in June, the AMA adopted several policies aimed at improving the prior authorization experience for patients and physicians. The AMA calls for insurers to provide more information in denial letters, offer real-time information about medications not requiring prior authorization, and impose greater legal accountability on insurers who cause patient harm by delaying or denying care.