Prior authorization is leading to over-utilization of health care services, unnecessary waste and avoidable patient harm, according to a new physician survey by the American Medical Association (AMA).

The survey, which was conducted in December 2022, debunks health insurers’ claims that the approval process they impose on health care providers helps with cost and quality control, and instead found that prior authorization imposes a toll on physicians and patients that exceeds its alleged benefits.

Specifically, physicians reported the following adverse outcomes and additional costs due to prior authorization (PA):

• 86% of physicians reported that PA led to higher overall utilization of health care services, resulting in unnecessary waste rather than cost-savings.
• 64% of physicians reported that patients initially received ineffective treatments due to PA-required step therapy.
• 62% of physicians reported that PA led to additional office visits.
• 46% of physicians reported that PA led to urgent or emergency care for patients.

Physician responses also called into question health insurers’ claims that prior authorization criteria reflect evidence-based medicine, as just 15% of physicians reported that prior authorization criteria were often or always evidenced-based.

Physicians also reported the following additional harms that resulted due to prior authorization:

• 33% reported a serious adverse event for a patient in their care, including hospitalization, permanent impairment or death.
• 89% reported a negative impact on patient clinical outcomes.
• 94% reported delays to necessary care.
• 80% reported patients abandoning a recommended course of treatment.

Additionally, 88% of physicians said that burdens associated with prior authorization were high or extremely high. The survey offered striking statistics about the administrative burdens of prior authorization. Medical practices reported completing an average of 45 prior authorizations per physician per week, a burden that physicians and their staff spent an average of two business days completing. More than two-thirds of physicians (35%) reported employing staff members to work exclusively on PA-related tasks.

On March 13, AMA submitted the findings of its survey along with comments supporting the Centers for Medicare and Medicaid Services’ proposed reforms to improve prior authorization.

At the state level, the California Medical Association (CMA) is sponsoring Senate Bill 598, authored by Senator Nancy Skinner, which would adopt a holistic approach to reforming the prior authorization process by allowing physicians to receive a one-year exemption from a health plan's prior authorization requirements if the physician’s prior authorization requests are approved at least 90% of the time.

Share Your Story

CMA is encouraging physicians and patients who have experienced delays in care due to prior authorization to share their stories. By adding your voice to the movement to reform prior authorization, you can help ensure that patients receive the care they need – when they need it.