Prior Authorization Continues to Burden Physicians, Adversely Impact Treatment, Survey Finds

Prior authorization (PA) is a common way for health plans to manage costs because the process requires healthcare professionals obtain health plan approval that a medication or service will be covered before it can be delivered to the patient.

The results of a new survey from the American Medical Association (AMA) have found that despite evidence of the harms and burdens of PA, it continues to be widely used. AMA has just released the results of the December 2021 survey of more than 1,000 practicing physicians.

“Waiting on a health plan to authorize necessary medical treatment is too often a hazard to patient health,” AMA President Gerald E. Harmon, M.D., said in a statement. “Authorization controls that do not prioritize patient access to timely, optimal care can lead to serious adverse consequences for waiting patients, such as a hospitalization, disability, or death. Comprehensive reform is needed now to stem the heavy toll that continues to mount without effective action.”

In 2018, AMA released a consensus statement with the American Hospital Association, AHIP, the American Pharmacists Association, the Blue Cross Blue Shield Association and the Medical Group Management Association calling for improvements in the PA process. In that statement, the organizations identified five areas of opportunity to improve PA programs and processes. The new survey asked respondents for their experiences and views on these five areas.

1. Selective Application of PA

The organizations recommended differentiating the application of PA based on quality measure performance, adherence to evidence-based medicine or contractual agreements to target PA requirements where they are needed and reduce the burden of PA.

However, in the survey, only 9% of physicians said they had contracts with health plans that offered programs that would exempt providers from PA. In addition, 29% did not know if the health plans they contract with offer these programs.

2. PA Program Review and Volume Adjustment

The consensus statement encouraged a regular review of the services and drugs subject to PA and continuous revision of PA requirements based on data analytics and updated clinical criteria.

Over the last five years, PA requirements for prescription medications and medical services has increased, according to 84% of the respondents. Only 1% said PA for medical services decreased somewhat or significantly and only 2% said the same for prescription medications. On average, one in five prescriptions require PA, the respondents reported.

3. Transparency and Communication Regarding PA

Effective, two-way communication between health plans, health care providers, and patients can ensure the timely resolution of PA requests, the organizations wrote in the consensus statement. They encouraged easy accessibility of PA requirements, criteria, rational and program changes.

A majority of physician respondents said it is difficult to determine whether a prescription medicine (65%) or medical service (62%) requires PA. Only 12% said it was easy to determine PA for a prescription medication and 15% said the same for medical services.

4. Continuity of Patient Care

For patients undergoing active treatment, continuity of care is crucial when there is a change in formulary coverage, treatment coverage or their health plan, the organizations noted in the consensus statement. Access to prescription medications can be affected by PA requirements even for patients on chronic, established therapy.

Only 1% of respondents said PA never interferes with continuity of care, 10% said it rarely interferes and 88% said PA does interfere with continuity of care, either sometimes, often or always.

5. Automation to Improve Transparency and Efficiency

The consensus statement encouraged providers, health systems, health plans and pharmacy benefit managers to adopt technology that can streamline and improve the PA process.

However, even in 2021, the phone was the most common method for completing PAs for prescriptions (56%) and medical services (59%). Furthermore, 23% and 24% said they use email or U.S. mail for prescription and medical services PAs, respectively, and 47% use fax for prescription PAs and 45% use fax for medical service PAs.

Half reported that they use their electronic health record or practice management system for prescription PAs, although the proportion was much lower for medical services (31%). Finally, 43% use the plan portal for prescription PAs and 41% use it for medical service PAs.