For much of 2020, as COVID-19 case surges threatened to overwhelm the U.S. health system, physicians faced onerous, business-as-usual insurer policies on top of a public health emergency.
In December, as the Centers for Disease Control and Prevention (CDC) data showed daily new COVID-19 cases reaching the once unthinkable total of 200,000, the American Medical Association (AMA) surveyed practicing physicians to measure the impact of health plans’ prior authorization (PA) requirements on patient care and practice burdens. The results were grim: surveyed physicians reported completing an average of 40 PAs during the previous week of practice, and this weekly PA workload for a single physician consumed 16 hours — the equivalent of two business days — of physician and staff time.
The fact that these significant administrative burdens taxed our practices during an unprecedented public health crisis is extremely disturbing. While many health insurers modified their PA policies during the pandemic’s early stages, nearly 70% of surveyed physicians reported that PA requirements were relaxed only temporarily or not at all, illustrating the limited reach of health plans’ policy adjustments.
PA Hurts Patients
Beyond these practice hassles, the AMA survey also captured the harmful effect of PA on patients and their health. An overwhelming majority (94%) of physicians reported that PA can delay access to medically necessary care. These delays represent far more than just the inconvenience of waiting for treatment, as physicians linked PA to adverse effects on care delivery and outcomes:
- 79% reported that PA can lead to treatment abandonment;
- 90% stated that PA can result in negative clinical outcomes; and
- 30% indicated that PA has led to a serious adverse event for a patient in their care, with 21% reporting that PA has led to a patient’s hospitalization.
These alarming data show the very real human costs of PA and raise serious questions about health plans’ claims that PA ensures appropriate, safe care and reduces costs. How can a process that so frequently leads to serious adverse events and patient hospitalizations reduce overall health care costs?
PA Burdens Are Growing
Despite the solid evidence that PA negatively impacts patients and physician practices, health plans continue to ramp up their utilization management programs. Health plans agreed over three years ago in the Consensus Statement on Improving the Prior Authorization Process — which was signed by 
America’s Health Insurance Plans and Blue Cross Blue Shield Association — to reduce the overall volume of PAs, yet they continue to introduce additional requirements. In the AMA survey, a strong majority of physicians reported that the number of PAs required for prescription medications and medical services has increased over the last five years. Even Medicare, which traditionally has not imposed PA, is now in the PA business: the 2020 Medicare Outpatient Prospective Payment System (OPPS) rule established PA requirements for five services that have cosmetic uses in addition to therapeutic indications, which burdens my specialty of plastic surgery. The 2021 OPPS rule hit close to home for readers of this blog, as it added PA to two neurosurgical service categories — cervical fusion with disc removal and implanted spinal neurostimulators. The AMA, the American Association of Neurological Surgeons, the Congress of Neurological Surgeons and numerous other concerned stakeholders recently sent a letter to the acting administrator of the Centers for Medicare & Medicaid Services urging a delay in implementing these new requirements.
Take Action
We see the growing harm that PA inflicts both on our profession and our patients with every passing year. It is time we step up and demand change. The AMA Advocacy Group has been active in Washington, urging Congress to support the reintroduction of the Improving Seniors’ Timely Access to Care Act (H.R. 3107 and S. 5044 in the 116th Congress). If passed, Medicare Advantage plans would be required to make many of the critical PA reforms outlined in the previously mentioned Consensus Statement, such as improving transparency and streamlining the process. All of you can play a role here in contacting your representatives to do the same. Since the problem is broader than just Medicare Advantage, the AMA is currently investigating further legislative moves to address insurance companies’ onerous PA policies.
The AMA has developed model legislation for use at the state level. We urge you to also work with your state medical association to support state PA legislation — you can join grassroots efforts to draw more attention to this critical issue. Visit FixPriorAuth.org to share your PA horror stories, watch videos of other physicians and patients telling how PA harms care delivery, engage on social media and sign a petition pushing for change.
Please also share this information with your patients — this is their problem, too. It is going to take all of us to FixPriorAuth, and legislators are more likely to respond to issues about which their constituents complain.
Editor’s Note: We hope that you will share what you learn from our posts. We invite you to join the conversation on Twitter by following @Neurosurgery and @AmerMedicalAssn, using the hashtag #FixPriorAuth.
Russell Kridel, MD, FACS
Chair, AMA Board of Trustees
interviews. As an applicant to neurosurgery, I was looking forward to learning how different programs operate compared to my home institution while also furthering my education in my field of interest. While COVID-19 significantly affected this plan, the pandemic also allowed for changes and innovations to the neurosurgery match — some of which may persist beyond the 2021 match cycle.
The most significant impacts of this cycle may be felt by those in states with few neurosurgery programs in their area. Obtaining letters of recommendation — considered “make or break” during the match — is undoubtedly a challenge for applicants without home programs. Standing out as an applicant — even with a home program and stellar letters — was also a challenge during this cycle. There is certainly a unique pressure to beef up “on-paper” qualifications such as the 
cycles. While we live in a unique time, I find that the sense that “we’re all in this together” has persisted through my virtual and in-person interactions with others in the field. We are, after all, made to be resilient to the many trials of medicine — both the expected and unexpected ones.
Somnath Das
The COVID-19 pandemic has resulted in many changes in the neurosurgery residency application process. Early decisions by the 
As the time to submit applications approached, I reached out to friends who applied last year, current residents and faculty members to better understand the programs and compile my list. While the process has certainly been different from years past, some positive things have come from these changes, including the longer home rotation, webinars and lecture series. To say that the virtual interview dramatically affected the ability of programs and applicants to gauge “fit” may be an overstatement, and the real drawback is likely from loss of longitudinal exposure during in-person rotations. Nevertheless, this year has been exciting for both programs and applicants, and I enjoyed seeing how programs showcased themselves through virtual interviews.
Sean Neifert
We can host more attendees than we would be able to with in-person sub-internships;
There is interest in hearing from neurosurgery residents from both within the U.S. and overseas;
Virtual symposia increase the breadth of neurosurgical experts’ ability to present their work, as well as the neurosurgery community able to attend;
Victor M. Lu, MD, PhD
Ingrid Menendez
Ricardo J. Komotar, MD, FAANS, FACS
Krystal L. Tomei, MD, MPH, FAANS, FACS, FAAP
Across the country, many non-urgent surgeries were canceled or delayed due to COVID-19. Overlapping surgery is the practice of a surgeon being responsible for more than one operating room at a time with non-critical portions of the procedure overlapping. When properly and ethically integrated, Drs. Menger and DiGiorgio use overlapping surgery in neurosurgery to better use health care resources and improve access to care.
