From the perspective of physicians, prior authorization puts enormous burdens on timely and quality patient care and is even putting patients at risk for adverse outcomes.
That’s according to a recent survey from the American Medical Association (AMA) that queried physicians about the approval process health insurers impose on medical services or drugs through prior authorization (PA). The findings, which were shared by AMA with federal health officials, underscore that the vast majority of physicians believe PA leads to unnecessary patient harm and unnecessary waste.
AMA has been very vocal about its desire for PA reforms that can ease burdens on physicians, particularly as the healthcare system is still facing major financial and operational challenges due to the COVID-19 pandemic, high inflation and higher staffing costs. Nearly all––86% of respondents said PA requirements led to higher overall utilization of healthcare resources, resulting in unnecessary waste rather than cost-savings. This is contrary to the intent of PA, which aims to control costs and eliminate waste.
“Health plans continue to inappropriately impose bureaucratic prior authorization policies that conflict with evidence-based clinical practices, waste vital resources, jeopardize quality care, and harm patients,” AMA President Jack Resneck Jr., MD, said in a statement “The byzantine system of authorization controls is rife with opportunities for reform and the AMA continues to work with federal and state officials on legislative solutions to reduce waste, improve efficiency, and protect patients from obstacles to medically necessary care.”
One of the biggest areas of concern for physicians is delays in care while health insurers consider coverage for certain treatments, therapies and drugs. A whopping 42% of respondents said care delays are often associated with PA, while 37% said delays are sometimes associated. Just 6% said care delays are rarely associated with PA, and 14% said always. Worse, 80% of respondents said PA can at least sometimes lead to treatment abandonment.
Most alarmingly, 33% of respondents said PA has led to a serious adverse event for their patient. One-quarter said PA has led to a patient’s hospitalization, while 19% said it has led to a life-threatening event or required intervention to prevent permanent impairment or damage. In addition, 9% reported PA has led to a patient’s disability/ permanent bodily damage, congenital anomaly/birth defect or death. Overall, 89% of physicians agreed the impact of PA on clinical outcomes has had a somewhat or significant negative impact.
Administrative burdens remain
On the productivity side, most physicians (86%) agreed the PA process lead to higher overall utilization of healthcare resources, such as additional office visits, initial use of less effective therapy due to step therapy requirements, emergency room visits, hospitalizations and more. Plus, more than half (58%) of physicians with patients in the workforce said PA has impacted patient job performance.
The loss of productivity really adds when also considering physician practices reported completing 45 PAs per physician, per week, the survey found. Overall, physicians and their staff spend an average of almost two business days (14 hours) completing PAs each week. Plus, two in five physicians said they have staff who work exclusively on PA.
The survey comes as healthcare industry groups are pushing for PA reforms. The Centers for Medicare and Medicaid Services (CMS) published a proposed rule in late 2022 that would aim to streamline some of the PA process and reduce burdens that could impact quality care for patients.
Amy joined TriMed Media as a Senior Writer for HealthExec after covering home care for three years. When not writing about all things healthcare, she fulfills her lifelong dream of becoming a pirate by sailing in regattas and enjoying rum. Fun fact: she sailed 333 miles across Lake Michigan in the Chicago Yacht Club "Race to Mackinac."