Physicians Say Health Insurer Prior Authorization Is Rising And So Are Care Delays

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Physician complaints about prior authorization – the vehicle that requires them to get approval from a health insurer before performing a procedure – is on the rise along with treatment delays that could harm patient health outcomes.

The complaints come as physicians generally have less autonomy than they are used to and doctors are worried about the increasing role of private health plans have in administering Medicare benefits for seniors.

Many doctors are no longer running their own practices and there’s a period of unprecedented buyouts of doctor practices. A report last year year from the Physicians Advocacy Institute and the consulting firm Avalere found corporate entities including health insurers have become a bigger player in owning doctor practices from 2019-2021, particularly during the onset of the pandemic.

Now comes the American Medical Association, which is pushing in Washington and state capitals for health insurance reforms of prior authorization, with a new survey of 1,000 practicing physicians showing such requirements lead to “to unnecessary waste and avoidable patient harm.”

The push by the nation’s largest physician organization comes as the Centers for Medicare & Medicare Services, at the direction of the Biden White House, considers reforming prior authorization policies, particularly for the increasingly popular Medicare Advantage plans. Such plans contract with Medicare to provide privatized benefits for seniors and now administer care for about half of all Medicare beneficiaries.

More than 40% of physicians say prior authorization delays access to necessary care, the AMA survey shows. That, in turn, can lead to a less efficient healthcare system and worse health outcomes than if their care had been more quickly authorized.

“Health plans continue to inappropriately impose bureaucratic prior authorization policies that conflict with evidence-based clinical practices, waste vital resources, jeopardize quality care, and harm patients,” AMA President Dr. Jack Resneck Jr. said.

Here are other highlights of the AMA’s survey, linked here:

* 86% of physicians said prior authorization requirements led to “higher overall utilization of health care resources, resulting in unnecessary waste rather than cost-savings.”

* 64% said resources were “diverted to ineffective initial treatments.”

* 46% said prior authorization led to “urgent or emergency care for patients.”

CMS is currently seeking comment on ways to improve prior authorization in several federal health insurance programs including Medicare Advantage, state Medicaid plans and the Children’s Health Insurance program.

For its part, the AMA Monday sent CMS administrator Administrator Chiquita Brooks-LaSure a 62-page letter offering its suggestions on improving prior authorization and related insurance regulations. “The Byzantine system of authorization controls is rife with opportunities for reform and the AMA continues to work with federal and state officials on legislative solutions to reduce waste, improve efficiency, and protect patients from obstacles to medically necessary care,” the AMA’s Resneck said.

Meanwhile, health insurance companies say they are working to “streamline processes, improve the quality of care, reduce costs, and enhance patients’ overall care experience,” America’s Health Insurance Plans (AHIP), the trade group and lobby for the nation’s health plans , said Monday.

As one example, AHIP cited increasing the adoption of electronic prior authorization.

“With that goal in mind, AHIP launched the Fast Prior Authorization Technology Highway (Fast PATH) initiative in 2020 to better understand the impact of (electronic prior authorization) on improving the (prior authorization) process, making health care more efficient and effective, Kristine Grow, AHIP senior vice president of communications and public affairs, said. “The findings show that (electronic prior authorization) delivers tremendous improvements, with a strong majority of experienced providers reporting faster time to patient care, fewer phone calls and faxes, better understanding of requirements, and faster time to decisions.”