prior authorization

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 116^th 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