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June 24, 2024


Delayed and disrupted care has become a predictable and miserable part of the patient experience as widespread use of prior authorization programs by the health insurance industry continues to negatively impact the delivery of necessary medical treatments, jeopardize quality care and harm patients. According to a new survey by the American Medical Association (AMA), the turmoil caused by excessive authorization controls continues to lead to serious or life-threatening events for patients, unnecessary waste and physician burnout.

Health plan overuse of prior authorization as a blunt cost-control tactic has placed patient health plans profits over patient safety and intruded on physicians’ ability to make health care decisions that best serve their patients’ interests.

In AMA’s latest annual survey of physicians about the impacts of prior authorization, respondents reported several alarming findings for patient harm and bad medical outcomes:  

  • Nearly a quarter of physicians (24%) reported that prior authorization led to a serious adverse event for a patient in their care, including hospitalization, life-threatening events, permanent bodily damage and death.  
  • More than nine in 10 physicians reported that prior authorization has a negative impact on patient outcomes (93%) and delays access to care (94%).  
  • More than three-quarters of physicians (78%) reported that struggles with health insurers during the prior authorization process led to patients abandoning treatment.   

The survey also cuts against health insurers’ claims that prior authorization reduces costs to the health care system and prevents overutilization of health care resources. Specifically, physicians reported the following on prior authorization’s waste and costs: 

  • 87% reported that prior authorization requirements led to higher overall utilization of health care resources. 
  • Physicians reported multiple ways in which the prior authorization process led to higher overall utilization of health care resources for patients in their care, including ineffective initial treatments (69%), additional office visits (68%), urgent or emergency care visits (42%) and hospitalizations (29%).  

The California Medical Association (CMA), AMA and nearly 400 health organizations are supporting the updated Improving Seniors’ Timely Access to Care Act of 2024 (S. 4532 / H.R. 8702), a strong, bipartisan bill to improve the prior authorization process for physicians and patients in Medicare Advantage.

At the state level, CMA is fighting to reform the broken prior authorization process by sponsoring SB 516, authored by Senator Nancy Skinner. If passed, the bill would remove unnecessary prior authorization requirements; streamline and modernize the process for submitting and appealing prior authorization requests; provide transparency and data on health plan actions; and require appeals of a prior authorization denial be reviewed by a physician of the same or similar specialty. 

 

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