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AMA survey finds prior authorization hurts patients and doctors

Article

Most doctors say delays in approval for treatment are impeding patient care. They also say excessive delays are undermining the argument that prior authorization helps control costs.

Doctors continue to seethe over the process of prior authorization with insurers, and a new survey finds physicians say it hurts patient care and leads to waste.

The American Medical Association released a survey Monday that found 94% of doctors say prior authorization leads to delays in patient care. One in three doctors (33%) say prior authorization has led to serious adverse events with their patients.

With prior authorization, doctors routinely must get approval from insurers for certain treatments, medications or procedures. Insurers say prior authorization is a necessary tool to control costs and avoid unnecessary procedures.

But doctors say prior authorization is actually undermining those goals of reducing costs.

A majority of doctors (62%) said prior authorization has led to additional office visits, with 64% saying authorization hassles have led to ineffective initial treatments. Nearly half of physicians (46%) said prior authorization has resulted in patients needing immediate care, including emergency department visits.

Jack Resneck, president of the AMA, said patients are paying the price of delays in prior authorization.

“Health plans continue to inappropriately impose bureaucratic prior authorization policies that conflict with evidence-based clinical practices, waste vital resources, jeopardize quality care, and harm patients,” Resneck said in a statement.

“The byzantine system of authorization controls is rife with opportunities for reform and the AMA continues to work with federal and state officials on legislative solutions to reduce waste, improve efficiency, and protect patients from obstacles to medically necessary care.”

Here are some key findings of the survey.

Dropping treatment: Four in five doctors (80%) said patients gave up on treatment because of problems getting authorization from insurers.

Job performance: A solid majority (58%) of doctors said prior authorization hurt the job performance of their patients.

High burdens: Most physicians (88%) characterized the burdens tied to prior authorization as “high” or “extremely high.”

Staffing pressures: More than a third of respondents (35%) said they employ staff solely for dealing with duties related to prior authorization.

Lack of evidence: Only 15% of doctors said the rejections of treatment plans are based on evidence.

The Centers for Medicare & Medicaid Services have proposed changes to prior authorization, which many in the healthcare industry have called a positive step. The CMS is asking for some payers to move to electronic authorizations by 2026 and also calls for a shorter timeline for decisions.

The AMA submitted comments to CMS largely in favor of the proposals, but also offered suggestions for improvement.

The CMS proposal calls for payers to offer specific reasons for denials of approval. The AMA wants the agency to go further and wants a provision “to ensure that the information is understandable and outlines clear, actionable next steps.”

The AMA also wants authorizations to be processed with 48 hours, and expedited requests to be handled within 24 hours.

Doctors routinely cite the hassles of prior authorization and other administrative burdens as leading contributors to physician burnout. In an AMA forum on physician burnout last week, panelists, including U.S. Surgeon General Vivek Murthy, said the hurdles of prior authorization are draining doctors.

The AMA has supported the inclusion of Medicare Advantage plans in efforts to reform prior authorization. Medicare Advantage plans have surged in popularity, with more than 30 million Americans enrolled. Healthcare advocates and lawmakers have said they are concerned about the problems doctors have encountered in getting approval for treatment.

Lawmakers introduced legislation last year to streamline prior authorization in Medicare Advantage plans, but the measure didn’t get through Congress. Some of those reform provisions are included in the CMS proposals.


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