Electronic Health Reporter

By Scott E. Rupp, publisher, Electronic Health Reporter.

Prior authorizations are hurting practices, the American Medical Association contends. According to the organization, prior authorization requirements have increased in the past five years, and 85 percent of physicians say the practice interferes with continuity of care. This is according to a new survey from the organization.

Prior authorization (PA) is a process requiring healthcare providers (physicians, pharmacists, medical groups and hospitals) to obtain advance approval from health plans before a prescription medication or medical service is delivered to the patient. While health plans and benefit managers say that PA programs are important to controlling costs, providers often find these programs to be burdensome and barriers to the delivery of necessary patient care.

The AMA’s report was conducted in partnership with the American Hospital Association, America’s Health Insurance Plans, American Pharmacists Association, Blue Cross Blue Shield Association and Medical Group Management Association, releasing the “Consensus Statement on Improving the Prior Authorization Process.” The statement “reflects agreement between healthcare providers and health plans on key reforms needed to reduce PA hassles and enhance patient-centered care.”

According to the 1,000 physicians interviewed, more than two-thirds of these fine folks said it’s difficult for them to determine whether a prescription or service needs prior authorization.

Alternatively, fewer than 10 percent of the physicians said they contract with a health plan that allows programs that can exempt providers from the requirement. Additionally, prior authorizations are primarily obtained by phone or fax, with just a bit more than 20 percent of physicians saying they are able to complete the requests through their electronic health records — which can be most efficient when that capability is allowed.

In a statement released with the survey findings, AMA charged insurance companies with a “year of foot-dragging and opposition” to prior authorization reforms.

According to the study, the AMA is encouraging the use of programs that selectively implement PA requirements based on stratification of healthcare providers’ performance and adherence to evidence-based medicine, but the results from the study show that only 8 percent of physicians report contracting with health plans that offer programs that exempt providers from PA. Likewise, the AMA wants an overall revision of PA requirements, including the list of services subject to PA, based on data analytics and  up-to-date clinical criteria. A majority (88 percent) of physicians report that the number of PAs required for prescription medications and medical services has actually increased over the last five years.

From the payer’s point of view, prior authorizations serve as a cost control that limits unnecessary care, and the practice has supporters in high places. For example, a Government Accountability Office report released in 2017 found that prior authorization in Medicare saved as much as $1.9 billion through March 2017. The Trump administration’s proposed budget also includes expanded prior authorization measures for Medicare. The fight over them doesn’t appear head for anything but an ugly stalemate.

Despite supposed improvements and agreement between some payers and groups like the AMA that PAs are burdensome, reforms are still needed and providers appear not to be seeing much fruit as a result of the efforts. In fact, a previous AMA report found that more than a quarter of physicians said prior authorizations lead to “serious or life-threatening events.”

In a statement by AMA president Barbara McAneny, prior authorizations can work against people seeking treatment and can be deadly. “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,” she said.

Meanwhile, the AMA is encouraging transparency and easy accessibility of PA requirements, criteria, rationale and program changes to contracted health care providers and patients/enrollees as seven in 10 physicians report that it is difficult to determine whether a prescription or medical service requires PA.

The AMA is encouraging healthcare professionals to join its grassroots PA reform campaign by signing a petition to Congress at www.fixpriorauth.org.