• Politics
  • Diversity, equity and inclusion
  • Financial Decision Making
  • Telehealth
  • Patient Experience
  • Leadership
  • Point of Care Tools
  • Product Solutions
  • Management
  • Technology
  • Healthcare Transformation
  • Data + Technology
  • Safer Hospitals
  • Business
  • Providers in Practice
  • Mergers and Acquisitions
  • AI & Data Analytics
  • Cybersecurity
  • Interoperability & EHRs
  • Medical Devices
  • Pop Health Tech
  • Precision Medicine
  • Virtual Care
  • Health equity

Most doctors say prior authorization delays care, causes patients to abandon treatment

News
Article

More than 9 in 10 say denials and delays from insurers are hurting patients, sometimes leading to serious adverse events, according to an AMA survey.

Physicians routinely bemoan the headaches involved in securing the approval of insurers for treatments, and the latest American Medical Association survey offers another snapshot of how much doctors detest the process of prior authorization.

Image: American Medical Association

Bruce Scott, president of the American Medical Association, says the prior authorization process hurts patients and needs reform.

Almost all doctors (94%) say delays in approval from insurers lead to delays in patient care. Nearly an identical number (93%) of respondents said the delays have a negative impact on patients, according to the AMA survey released Tuesday.

About a quarter of doctors (24%) said prior authorization delays have led to serious adverse events for patients, including hospitalization, permanent impairments, and in some cases, death.

AMA President Bruce A. Scott, MD, the AMA president, wrote in a column accompanying the survey that patients are paying the price for these delays.

“Across the country, physicians see firsthand the dangerous, harmful-and sometimes deadly-consequences of prior authorization,” Scott wrote in the column.

Doctors, hospitals and insurers have long clashed over prior authorization, which requires clinicians to obtain approval from insurers before moving ahead with treatment plans or procedures. The AMA releases surveys on prior authorization annually, with most doctors saying the process contributes to worse outcomes.

Insurers argue that prior authorization plays a necessary role in controlling the costs of healthcare, as well as avoiding expensive procedures that may not be medically necessary. AHIP, the trade association representing insurance companies, says prior authorization is one of a host of tools to promote “safe, timely, evidence-based, affordable, and efficient care.”

But physicians say the delays in prior authorization prevent some patients from getting the care they need, and doctors have urged lawmakers to reform the process.

Doctors have said they understand the need for insurance approval for less common procedures that may have a high price tag, but they say insurers are putting up too many roadblocks to common treatments that eventually get approved.

Some patients ultimately give up on treatments due to the delays. More than 3 of 4 doctors (78%) say prior authorization delays can result in patients abandoning recommended treatments.

Some doctors also give up after insurers reject a course of treatment plan, the survey finds.

Only about 1 in 5 physicians (18%) said they always appeal an insurer’s denial. Some say they don’t appeal because experience shows they may not get approval, or they don’t have the manpower to appeal. More than 1 in 3 doctors (35%) say they have staff who work solely on prior authorization requests or appeals. Physicians routinely cite the prior authorization process as a leading cause of burnout.

In his column, Scott recounts his own prior authorization battles. An otolaryngologist, Scott writes that he was treating a patient with a tumor growing in her sinus near her eye. The patient’s insurer denied approval for a surgery because the patient hadn’t tried an antibiotic and a nasal spray, “neither of which was going to cure the tumor,” Scott writes.

Scott called the insurer's medical director and secured approval for the surgery. But he writes that the patient endured added stress unnecessarily. “That’s just wrong, and our patients deserve better,” Scott wrote.

Gary Price, the president of the Physicians Foundation, told Chief Healthcare Executive® in a recent interview that prior authorization is in dire need of reform.

“Prior authorization, it's gone from being just an annoying role in taking care of patients,” Price said. “It's become a full-fledged obstacle course that frustrates physicians. It delays patient care. It can even prevent good patient care. It lowers the quality of that care. And simultaneously, it's increasing the cost.”

Delays in care contribute to higher costs because they lead to hospitalizations and other complications, Scott and other physicians argue.

The federal government has developed new regulations to change the prior authorization process, and healthcare groups say the changes will offer some relief. Beginning in 2026, insurers will have to respond more quickly to requests, and requests will be handled electronically.

But advocates for doctors and other healthcare groups say they want Congress to take more action. They say even under the final rule, the response period is too long: insurers will still have 72 hours for urgent requests and seven days for standard requests. Critics note the regulation doesn’t cover prescription drugs.

The American Hospital Association is urging the Senate to pass a bill that would speed approvals for Medicare Advantage Plans. The AHA is backing a bill that would streamline prior authorization requirements in those plans.

Critics have said patients and physicians are seeing more hurdles in authorizations under Medicare Advantage plans. Some lawmakers tried unsuccessfully to pass reforms in the last congressional session, and healthcare advocates, including the AMA, are pushing Congress to approve legislation before the current session ends in December.

(See part of our conversation with Gary Price of the Physicians Foundation about prior authorization.)

Recent Videos
Image: Johns Hopkins Medicine
Image credit: ©Shevchukandrey - stock.adobe.com
Image: Ron Southwick, Chief Healthcare Executive
© 2024 MJH Life Sciences

All rights reserved.