For example, a physician wants to prescribe a particular medicine to a patient to help treat that patient’s condition. Before the patient can get the prescribed drug, the doctor must convince the health plan the drug is actually necessary to treat the patient. But this is exactly the kind of medical judgment that physicians are trained to make after spending the better part of a decade in medical school and residency.
The burdensome prior authorization process leads to care delayed and care denied. In April, the Health and Human Services Department Office of Inspector General reported that Medicare Advantage plans engaged in improper denials of services that delayed or prevented patient care, even though the services they studied fulfilled Medicare coverage requirements. As currently practiced, this process essentially puts a health insurance administrator in the doctor’s office to second-guess medical judgments. In many cases, the third-party administrator who makes the decision on a prior authorization request is not a physician. Due to their lack of medical training, they know far less about the patient’s condition or the treatment being prescribed than the physician who is seeing the patient.
Prior authorization can lead to serious and harmful delays in care, and it is often cited as one of the leading administrative burdens in medicine today. In 2021, the American Medical Association conducted a survey of physicians to gauge their experiences with prior authorization. This survey found that 88% of physicians described the burden of dealing with prior authorization as “high” or “extremely high,” and over 90% report that the process results in delayed access to necessary care for their patients. More than one-third of the physicians reported that prior authorization requirements had led to a serious adverse event (such as hospitalization or permanent bodily damage) for a patient in their care.
Even if an adverse determination is eventually overturned on appeal, the length of the process unnecessarily delays care and even leads to some patients abandoning treatment altogether. Overall, 91% of physicians believe that prior authorization has an overall negative impact on patient clinical outcomes.
Policymakers in Congress and in state legislatures are taking note and pursuing common-sense reforms to prior authorization to streamline the process and ensure that physicians can deliver care without facing unnecessary administrative burdens that waste time and lead to worse patient outcomes. One bill with broad bipartisan support would establish a more efficient electronic prior authorization process and require greater transparency on denials. I also recently introduced a bill, the Reducing Medically Unnecessary Delays in Care Act, to require any prior authorization determinations in Medicare and Medicare Advantage to be made by licensed physicians who are board-certified in the relevant specialty. Through such reforms, we can craft policies that empower doctors to focus on patients, not paperwork.
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