Nearly 1 in 4 physicians say prior authorization led to a serious adverse event for one of their patients, according to a survey released Tuesday by the American Medical Association.
Another 16% of physicians reported prior authorization caused at least one of their patients to be hospitalized. And more than 9 in 10 physicians said prior authorization regularly delays access to necessary care for their patients. The AMA said the results are evidence that insurers have made little progress in reforming prior authorization since the healthcare industry issued a consensus statement about the need for reform more than two years ago.
"These new survey results highlight that practices continue to devote significant time—an average of nearly two business days per week per physician—navigating prior authorization's administrative obstacles. Even more concerning, this process can harm our patients," AMA President Dr. Susan Bailey said in a statement.
Providers are pushing Congress to pass bipartisan legislation to force Medicare Advantage plans to streamline and standardize prior authorization and increase health plan transparency, among other things. Nearly 220 members of the House of Representatives have co-sponsored H.R. 3107, the Improving Seniors' Access to Timely Care Act.
"Prior authorization can and should be used appropriately to guarantee appropriate patient care and avoid unnecessary costs, and my legislation sets up the guardrails to make that happen and dramatically ease physician burden and burnout," Rep. Suzan DelBene (D-Wash.) said in a press release.
Providers are concerned about prior authorization requirements because they often devote considerable time, money and effort to receive approval from insurers to deliver necessary care. But many healthcare experts argue prior authorization requirements are needed to control healthcare costs and spending by reducing unnecessary care and limit fraud.
According to the nonpartisan Kaiser Family Foundation, Medicare Advantage plans tend to use prior authorization for high-cost services used by sicker enrollees like inpatient care and drugs covered under Medicare Part B.
A 2018 analysis of CMS Medicare Advantage enrollment and benefit information by KFF found 4 in 5 Medicare Advantage beneficiaries enrolled in plans with prior authorization requirements. While just 12% of plans required prior authorization for preventative services, that figure jumped to more than 70% for inpatient hospital stays, Part B drugs, skilled nursing facility stays and durable medical equipment. More than half of Medicare Advantage enrollees signed up for plans that require prior authorization for mental health services.
HHS' Office of the Inspector General said in a 2018 report that Medicare Advantage plans often deny necessary care.
Experts say plans can reduce prior authorization requirements without increasing overall utilization and costs if they improve how they collect and analyze health data and shift internal resources to case and disease management. But most insiders agree that the healthcare industry needs to move to value-based payment to reduce prior authorization requirements for providers significantly. Health systems and group practices have resisted that change so far.
