Prior Authorization Reform

Responding to unreasonable hurdles for patients seeking care, a coalition including the American Medical Association (AMA) and 16 other health care organizations today urged health plans, benefit managers and others to propose prior authorization reform requirements imposed on medical tests, procedures, devices, and drugs.

The coalition, which represents hospitals, medical groups, patients, pharmacists and physicians, says that requiring pre-approval by insurers before patients can get certain drugs or treatments can delay or interrupt medical services, divert significant resources from patient care and complicate medical decisions. Concerns that aggressive prior authorization programs place cost savings ahead of optimal care have led Delaware, Ohio and Virginia to recently join other states in passing strong patient protection legislation.

Given the potential barriers that prior authorization can pose to patient-centered care, the coalition is urging an industry-wide reassessment of these programs to align with a newly created set of 21 principles. Prior authorization programs could be improved by applying the principles’ common-sense concepts grouped in five broad categories:

  • Clinical validity. This includes concepts such as UM criteria being based on up-to-date clinical criteria and never cost alone. This category also highlights the need for flexibility to meet patient-specific needs. Principle No. 2, for example, says: “[UM] programs should allow for flexibility, including the timely overriding of step therapy requirements and appeal of prior authorization denials.”
  • Continuity of care. This set of principles is designed to ensure that patients’ care isn’t disrupted by prior-authorization requirements. For example, principle No. 4 says: “Utilization-review entities should offer a minimum of a 60-day grace period for any step-therapy or prior-authorization protocols for patients who are already stabilized on a particular treatment upon enrollment in the plan. During this period, any medical treatment or drug regimen should not be interrupted while the utilization management requirements (e.g., prior authorization, step therapy overrides, formulary exceptions, etc.) are addressed.”
  • Transparency and fairness. The principles in this category address the need for detailed explanations for denials and full public disclosure of all coverage restrictions in a searchable, electronic format. As another example, principle No. 9 states, “Utilization-review entities should provide, and vendors should display, accurate, patient-specific, and up-to-date formularies that include prior authorization and step therapy requirements in electronic health record (EHR) systems for purposes that include e-prescribing.”
  • Timely access and administrative efficiency. This includes principles that establish maximum-response times for UM decisions and seek health plans’ acceptance of electronic prior authorizations. Another example in this category is principle No. 13, which says, “Eligibility and all other medical policy coverage determinations should be performed as part of the prior-authorization process. Patients and physicians should be able to rely on an authorization as a commitment to coverage and payment of the corresponding claim.”
  • Alternatives and exemptions. This category includes a call for health plans to offer at least one alternative to prior authorization, such as a “gold card” program. Another option is laid out in principle No. 21: “A provider that contracts with a health plan to participate in a financial risk-sharing payment plan should be exempt from prior authorization and step-therapy requirements for services covered under the plan’s benefits.”

Prior Authorization Reform

“Strict or bureaucratic oversight programs for drug or medical treatments have delayed access to necessary care, wasted limited health care resources and antagonized patients and physicians alike,” said AMA President Andrew W. Gurman, M.D. “The AMA joins the other coalition organizations in urging health insurers and others to apply the reform principles and streamline requirements, lengthy assessments and inconsistent rules in current prior authorization programs.”

The data entry and administrative tasks associated with prior authorization reduce time available for patients. According to a new AMA survey, every week a medical practice completes an average of 37 prior authorization requirements per physician, which takes a physician and their staff an average of 16 hours, or the equivalent of two business days, to process.

The AMA survey illustrates that physician concerns with the undue burdens of preauthorizing medical care have reached a critical level. Highlights from the AMA survey include:

  • Seventy-five percent of surveyed physicians described prior authorization burdens as high or extremely high.
  • More than a third of surveyed physicians reported having staff who work exclusively on prior authorization.
  • Nearly 60 percent of surveyed physicians reported that their practices wait, on average, at least 1 business day for prior authorization decisions—and  more than 25 percent of physicians said they wait 3 business days or longer.
  • Nearly 90 percent of surveyed physicians reported that prior authorization sometimes, often, or always delays access to care.

The AMA survey findings indicate there is a real opportunity to improve the patient experience while significantly reducing administrative burdens for both payers and physicians by reforming prior authorization and utilization management programs.

 Prior Authorization Reform

The AMA and other coalition organizations welcome the opportunity to work collaboratively with health plans and others to create a partnership that lays the foundation for a more efficient prior authorization process. In addition to the AMA, the coalition includes the: American Academy of Child and Adolescent Psychiatry, American Academy of Dermatology, American Academy of Family Physicians, American College of Cardiology, American College of Rheumatology, American Hospital Association, American Pharmacists Association, American Society of Clinical Oncology, Arthritis Foundation, Colorado Medical Society, Medical Group Management Association, Medical Society of the State of New York, Minnesota Medical Association, North Carolina Medical Society, Ohio State Medical Association and Washington State Medical Association.