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Payers Slow to Update Prior Authorization, Limit Patient Care Access

Few physicians report that their payer partners are streamlining prior authorization, posing a threat to timely patient care access.

patient care access prior authorization

Source: Thinkstock

By Sara Heath

- Healthcare payers are slow to adopt best practices to streamline the prior authorization process, putting at risk timely patient care access and adding administrative burden to providers, according to a recent American Medical Association (AMA) survey.

Prior authorization is a cost containment strategy that requires physicians to submit certain qualifying materials to payers to be reviewed by a panel before payers cover a certain drug or treatment. While insurers have these requirements to cut costs on treatments that may not be medically necessary or cost-effective, prior authorization is widely accepted as a significant barrier to patient care.

“Physicians follow insurance protocols for prior authorization that require faxing recurring paperwork, multiple phone calls and hours spent on hold. At the same time, patients’ lives can hang in the balance until health plans decide if needed care will qualify for insurance coverage,” said AMA President Barbara L. McAneny, MD.

“In previously released AMA survey results, more than a quarter of physicians reported that insurers’ extended business decision-making process led to serious adverse events for waiting patients, such as a hospitalization or disability. The time is now to fix prior authorization.”

Just last year, the AMA, alongside leading payer trade groups such as America’s Health Insurance Plans (AHIP) and the Blue Cross Blue Shield Association, issued a statement calling for streamlined prior authorization practices.

READ MORE: 91% of Docs Say Prior Authorization Delays Patient Care Access

One year later, those best practices are not always being adhered to, this latest survey from the AMA showed.

For example, the statement called for grandfathering in physicians in good standing, allowing them to avoid some prior authorization burdens. Specifically, the letter stated that physicians with certain prescribing patterns and care quality scores should bypass some prior authorization requirements.

However, only 8 percent of physicians said they have entered into such contracts with payers. AMA did not state how many physicians would qualify for such a contract based on those prescribing habits and care quality scores.

The statement also noted that payers should routinely review the drugs or treatments that require prior authorization, removing those that have low denial rates. Low variation in drug use or low denial rates would suggest a treatment is effective and does not necessarily need payer review.

But 88 percent of physicians said they have encountered an increase in the number of drugs requiring prior authorization, not fewer, the AMA survey said. Eighty-six percent of physicians said the number of services that require prior authorization has also increased.

READ MORE: AMA Calls to Eliminate Prior Authorization for MAT Patient Access

Furthermore, payers are behind on clarifying prior authorization rules, the survey revealed. Sixty-nine percent of physician respondents said it was difficult to determine whether a drug or service required prior authorization.

In 2018’s statement, payers and provider agreed those rules should be clarified, making it easier for physicians to select treatments and engage in the prior authorization process.

Additionally, 85 percent of physicians said prior authorization is disrupting care continuity for patients, despite the fact that the 2018 statement called for rules that allow for continuous care.

Finally, the survey revealed that the payer industry is behind on automating the prior authorization process, with only 21 percent of physicians saying their EHR allows for electronic prior authorization. This comes even as industry leaders called for prior authorization automation.

This is not to say nothing is being done to overcome prior authorization hurdles, the AMA stated. Thirty-two state legislatures have proposed regulations that would streamline prior authorization. In states like Pennsylvania, these protocol include avenues for patients to access medication-assisted treatment (MAT) for opioid use disorder without prior authorization.

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

Other states and healthcare providers should follow this model, said McAneny.

“There is no reason for insurers to use prior authorization for medications to treat opioid use disorders when patients’ lives hang in the balance,” said McAneny. “The AMA urges all health insurers to join with the medical community to enact vital legislation that is an important step in reversing the opioid epidemic.”

Prior authorization has gotten in the way of clinicians delivering patient-centered care, according to a February 2019 AMA survey. Prior authorization protocol leaves patients waiting up to three days before receiving their treatment, a timeframe many providers say is too long, especially when the patient has a serious illness.

Twenty-eight percent of the survey’s 1,000 physician respondents said prior authorization requirements have led to serious or life-threatening health events. Ninety-percent of respondents said prior authorization has negative consequences for patient care quality.

“The AMA survey continues to illustrate that poorly designed, opaque prior authorization programs can pose an unreasonable and costly administrative obstacle to patient-centered care,” AMA Chair Jack Resneck, Jr, MD, said in a statement. “The time is now for insurance companies to work with physicians, not against us, to improve and streamline the prior authorization process so that patients are ensured timely access to the evidence-based, quality health care they need.”

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