April 13, 2021
As new cases of COVID-19 in the United States were peaking in late 2020, most physicians reported that health plans continued to impose bureaucratic prior authorization policies that delay access to necessary care and sometimes result in serious harm to patients, according to new survey results from the American Medical Association (AMA).
Although some payors had relaxed prior-authorization requirements early in the public health emergency, almost 70% of 1,000 practicing physicians surveyed in December 2020 reported that health insurers had either reverted to past prior authorizations policies or had never relaxed these policies in the first place. More than nine in 10 physicians (94%) reported care delays while waiting for health insurers to authorize necessary care, and nearly four in five physicians (79%) said patients abandon treatment due to authorization struggles with health insurers.
Nearly one-third (30%) of physicians reported that prior authorization requirements have led to a serious adverse event for a patient in their care, according to the AMA survey.
While the health insurance industry says prior authorization criteria reflect evidence-based medicine, the physician experience casts doubt on the credibility of this claim. Only 15% of physicians reported that prior authorization criteria were often or always based on evidence-based medicine.
Other critical physician concerns highlighted in the AMA survey include:
- Nine in 10 physicians (90%) reported that prior authorizations programs have a negative impact on patient clinical outcomes.
- A significant majority of physicians (85%) said the burdens associated with prior authorization were high or extremely high.
- Medical practices complete an average of 40 prior authorizations per physician, per week, which consume the equivalent of two business days (16 hours) of physician and staff time.
- To keep up with the administrative burden, two out of five physicians (40 %) employ staff members who work exclusively on tasks associated with prior authorization.
The findings of the AMA survey illustrate a critical need to streamline or eliminate low-value prior-authorization requirements to minimize delays or disruptions in care delivery.
The California Medical Association (CMA) has joined with AMA to urge for industry-wide improvements in prior authorization programs to align with a set of 21 principles intended to ensure that patients receive timely and medically necessary care and medications and reduce the administrative burdens. CMA and more than 100 other health care organizations have supported those principles. CMA and AMA welcome the opportunity to work collaboratively with health plans and others to create a more transparent efficient, fair and appropriately targeted prior authorization process.
CMA is also sponsoring a legislative effort in California (SB 250, Pan) to reduce administrative burdens in physician practices, so physicians can spend less time on paperwork and billing and more time dedicated to patient care. SB 250 will reform prior authorization processes and relieve physicians from having to repetitively submit prior authorizations for a set period of time. The bill would also streamline the billing process for physicians in hospital settings by requiring payors to collect enrollee cost-sharing amounts directly (including deductibles).