Reform to prior authorization could be coming

Physicians and other healthcare advocates have lambasted the process of prior authorization for years, but some are seeing a chance for reform.

Lawmakers in Congress are pushing legislation to streamline the prior authorization process in Medicare Advantage plans, which are utilized by millions of seniors. In prior authorization, physicians and practices must get approval from insurers on certain medications and treatments.

U.S. Rep. Suzan DelBene, D-Wash., has sponsored a bill to revamp prior authorization in Medicare Advantage plans. The House passed the bill, and it's now in the Senate.

While insurers contend prior authorization is designed at reducing unnecessary treatments and wasteful spending, doctors say the process is too demanding and often results in patients denied medications or at least seeing delays in treatment. They also say it siphons time from healthcare workers who are already overworked and understaffed, adding it’s a leading contributor to burnout.

Although some say demands eased during the early months of the COVID-19 pandemic, some healthcare providers contend the demands are getting more burdensome. Healthcare organizations such as the American Medical Association and the Medical Groups Management Association have been pressing Congress for relief.

Now, there’s optimism for change. The House of Representatives passed a bill this month that would change the authorization process for Medicare Advantage plans, which serve 28 million Americans and are gaining in popularity. U.S. Rep. Suzan DelBene, D-Wash., sponsored the House bill, dubbed the “Improving Seniors’ Timely Access to Care Act.”

The bill also commands strong support in the Senate, with 42 co-sponsors.

“I think we have a good shot” at Senate passage, said Claire Ernst, director of government affairs for the MGMA.

Under the bill, Medicare Advantage plans would be required to tell the Centers for Medicare & Medicaid Services how often they are using prior authorization and the rate of approvals and denials. The U.S. Department of Health and Human Services would have to set up a process for “real-time” decisions for services that are typically approved.

The legislation would also establish an electronic prior authorization process, something healthcare organizations have wanted for years.

Even with broad support, Senate passage isn’t a lock, simply because there isn’t much time before the Congressional session ends in January (a factor affecting other healthcare priorities, such as telehealth reform). Lawmakers will be devoting much of their attention to the mid-term elections in November. Ernst said the bill will likely be addressed after the fall elections.

“I’m hoping by the end of the year, we will have passed both chambers and get this signed into law so we don’t have to do this again,” Ernst said.

‘It’s a massive burden’

While prior authorization has been around for years, doctors said the demands are growing, with a significant amount of time being spent on requesting approvals for treatments, and then appealing if requests are denied.

Nearly 4 in 5 medical groups (79%) said prior authorization requirements increased over the past year, according to a survey by the MGMA released in March.

Most doctors say the process interferes with patient care.

In an AMA survey released in February, 93% of doctors said the prior authorization process leads to delays in patient care. More than four of five doctors (82%) said prior authorization sometimes leads to patients abandoning a recommended course of treatment. Roughly a third of doctors surveyed (34%) said prior authorization delays have led to adverse events in patients they were treating.

Chris Phillips, a rheumatologist in Paducah, Kentucky, told Chief Healthcare Executive that he has seen patients give up after denial.

“It’s a massive burden in time for staff,” Phillips said of the prior authorization process. “It leads to delays in therapy for patients.”

Payers say the goal is to ensure patients get the appropriate treatment and curb unnecessary spending, but Phillips said the process is limiting care.

“That all sounds good at 30,000 feet,” he said. “When you’re in the room with the patient, the medical provider has their medical training for a reason. It’s hard for the payer to replace our medical decision making from afar.”

“They’re making the medical decision for us, which is unfortunate,” Phillips said.

Many of his patients suffer from rheumatoid arthritis and autoimmune diseases. While his practice usually doesn’t see life-threatening outcomes when treatment is delayed, patients who don’t get timely approval tend to miss work more often.

With rheumatoid arthritis, “the earlier you treat it … the better the long-term outcomes,” Phillips said.

Insurers eased prior authorization processes in the height of the pandemic, Phillips said, “and we were thankful for that.”

“That’s all gone away at this point,” he said. “It’s really been back to business as usual.”

Doctors also described frustrating hassles with the authorization process, such as being issued a denial on a Friday and given 72 hours to respond, including the weekend. In some circumstances, a payer’s response would arrive on a Friday, and the deadline would expire Monday, Phillips said.

In some cases, they would eventually get approval, but not before starting the authorization process over.

‘An onerous process’

Ruth Williams, an ophthalmologist in Wheaton, Ill., recounted some of her headaches with prior authorization. In an interview this spring, Williams told Chief Healthcare Executive about requests for cataract surgery that were denied. Some patients had surgeries canceled, Williams said.

“They say they approve 90% of cases,” she said. “If they are going to approve 90% of patients, why do they make us go through such an onerous process?”

After pressure from healthcare groups, Aetna announced in July that it was dropping its prior authorization requirement for cataract surgeries. When Aetna introduced the prior authorization policy in 2021, the American Academy of Ophthalmology said it had an immediate impact. The academy estimated 10,000 to 20,000 patients had cataract surgeries delayed in July 2021 alone.

After Aetna rescinded the authorization requirement, Stephen D. McLeod, CEO of the American Academy of Ophthalmology, said in a statement that the policy “was very difficult to understand since the indications for surgery are well established and the benefits clear.”

“This is an incredibly common procedure with some 4 million Americans undergoing cataract surgery each year,” he said. “It has an extremely high success rate with regards to safety and vision improvement, and studies have consistently shown that cataract surgery improves quality of life, lowers the risk of falls and car accidents, and is associated with reduced cognitive decline amongst older adults.”

Even with her experiences, Williams said she understands the need for prior authorization in some circumstances.

“We’re not saying prior authorization needs to be eliminated,” Williams said. “It does have its role.”

“Prior authorization as a mechanism, when it’s used appropriately, has a place in healthcare,” she added. “If someone is using an expensive drug for cancer treatment, it can be an evaluation of a cheaper alternative that’s equally effective, and that’s fair.”

However, Williams said it’s clear prior authorization must be improved.

“The process is not respectful of the patients and the doctors and their schedules,” she said.

‘It’s high on the list’

Healthcare leaders and physicians said the prior authorization demands contribute to burnout, or at minimum, add stress to doctors and healthcare workers who spend hours on approval requests and appeals.

“There’s a million other stab wounds that lead to burnout. This is not the biggest one, but it’s high on the list,” Phillips said.

In a broad Health Affairs roundtable on mental health last week, panelists noted administrative tasks play a big role in physician burnout. Lawrence Casalino, professor of healthcare policy and research at Weill Cornell Medical College, said processes such as prior authorization take a lot of time “and drive physicians crazy.”

In May, U.S. Surgeon General Vivek Murthy issued an advisory urging healthcare organizations to address burnout, and it mentioned reducing demands of prior authorization. Among many recommendations in the report, Murthy suggested “reviewing the volume of and requirements for prior authorizations together with health workers” and “streamlining fax-based work such as prior authorizations to electronic and automated systems.”

• Read more: More doctors are suffering from burnout, and health systems must do more

Too many prior authorization requests aren’t handled electronically, health leaders say. The Council for Affordable Quality Healthcare (CAQH) compiles an annual report, the 2021 CAQH Index, which measures progress in handling administrative tasks electronically. Prior authorization is one administrative function that is lagging behind.

The report found 26% of prior authorization requests are handled fully electronically, and  39% authorizations were partially electronic. More than a third of prior authorizations (35%) were fully manual, meaning they were submitted by phone, fax, email or mail. DelBene, sponsor of the prior authorization bill, said on the House floor, “It’s 2022, and even Congress has moved beyond faxing.”

While the prior authorization bill focuses on Medicare Advantage and not the whole healthcare industry, supporters nonetheless say it would represent a significant accomplishment.

Advocates are making it clear to Congress that they can help some of America’s most vulnerable patients avoid unnecessary delays in care, said Ernst, the MGMA’s government relations director.

“That appeals to lawmakers on both sides of the aisle,” Ernst said.