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92% of Docs Say Prior Authorization Harms Patient Access to Care

Prior authorization can cause delays in patient access to care and treatments, ultimately damaging clinical quality outcomes.

patient access to care prior authorization

Source: Thinkstock

By Sara Heath

- Ninety-two percent of clinicians say lengthy prior authorization protocols have impeded timely patient access to care and harmed patient clinical outcomes, according to a new survey released by the American Medical Association (AMA).

Prior authorization is the process by which health payers approve of certain treatments for patients. Treating clinicians must fill out certain paper work, which the insurer then processes. Payers require this process for many treatments because they want to ensure patients truly need the treatment the physician is prescribing. Prior authorization is a part of a money-saving process for healthcare payers.

Although most insurers eventually approve of patient treatments, prior authorization delays the care process which at best can be frustrating for patients and providers, according to AMA Chair-elect Jack Resneck Jr, MD.

“Under prior authorization programs, health insurance companies make it harder to prescribe an increasing number of medications or medical services until the treating doctor has submitted documentation justifying the recommended treatment,” Resneck said in a statement.

“In practice, insurers eventually authorize most requests, but the process can be a lengthy administrative nightmare of recurring paperwork, multiple phone calls and bureaucratic battles that can delay or disrupt a patient’s access to vital care,” Resneck continued. “In my own practice, insurers are now requiring prior authorization even for generic medications, which has exponentially increased the daily paperwork burden.”

READ MORE: Efficient Prior Authorization Key for Patient Access to Treatment

The survey of over 1,000 providers revealed that prior authorization delays care at least one day for two-thirds of providers. About 30 percent of providers said prior authorization usually takes up to three business days.

These long wait times have negative impacts on patient experience and patient care. Seventy-eight percent of providers said their patients sometimes, often, or always abandon treatment protocol when they have to wait for prior authorization clearances.

Overall, physicians are reporting negative impacts associated with prior authorization clearances. Only 2 percent of respondents said they felt at least a somewhat positive impact from prior authorization, and only 7 percent said there was no impact from prior authorization.

Thirty-one percent of providers said prior authorization had a somewhat negative impact on their patients, while 61 percent said the impact was significantly negative.

Prior authorization protocol has negative impacts on more than just the patient experience. Medical practices are also feeling negative consequences for having to process prior authorization forms. Eighty-four percent of providers said prior authorization protocol caused a high or extremely high burden on their practice.

READ MORE: How Prior Authorization Affects Timely Patient Treatment Access

Only 4 percent said there was a low or extremely low burden on their practice.

On average, physician practices have to process 29.1 prior authorizations per clinician weekly. This takes about 14.6 hours each week to complete prior authorization requests.

The job is usually not complete after the provider submits her first prior authorization request. Clinicians sometimes need to repeat a certain procedure or acute medication to stabilize a chronically ill patient. In those cases, 79 percent of providers either sometimes, often, or always have to re-submit the prior authorization forms.

This workload has driven 34 percent of physician practices to hire a staff member solely dedicated to completing prior authorization requests.

AMA has long been critical of the role prior authorizations play in healthcare. While the organization has acknowledged the need to cut healthcare costs, Resneck says it is also important to manage patient access to necessary treatments.

READ MORE: What Providers Should Know to Improve Patient Access to Healthcare

“The AMA survey illustrates a critical need to help patients have access to safe, timely, and affordable care, while reducing administrative burdens that take resources away from patient care,” Resneck explained. “In response, the AMA has taken a leading role in convening organizations representing, pharmacists, medical groups, hospitals, and health insurers to take positive collaborative steps aimed at improving prior authorization processes for patients’ medical treatments.”

AMA has been at the forefront of a movement calling for reforms to the prior authorization process. In January 2017, the organization led a coalition calling on the healthcare industry to overhaul prior authorization protocol to adhere to 21 principles. Those principles sought to preserve timely patient access to care.

In January 2018, AMA joined the likes of the American Hospital Association (AHA), America’s Health Insurance Plans (AHIP), Medical Group Management Association (MGMA), the American Pharmacists Association (APhA), and Blue Cross Blue Shield Association urging the industry to reevaluate prior authorization.

“The prior authorization process can be burdensome for all involved—health care providers, health plans, and patients,” the industry groups wrote in their consensus statement.

“Yet, there is wide variation in medical practice and adherence to evidence-based treatment,” they continued. “Communication and collaboration can improve stakeholder understanding of the functions and challenges associated with prior authorization and lead to opportunities to improve the process, promote quality and affordable health care, and reduce unnecessary burdens.”

To its credit, the payer industry says it is committed to at least reconsider this process. A February 2018 survey of health payers found that 96 percent of companies are interested in electronic prior authorization. Electronic prior authorization should make the paperwork less burdensome for providers and speed up authorization turnaround time.

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