Current prior authorization practices drive worse patient outcomes and increased utilization of healthcare resources due to unnecessary encounters or ineffective care, a majority of physicians said in a survey conducted by the American Medical Association.
Released this week, the December poll of 1,001 practicing physicians outlined unintended outcomes resulting from treatment approval processes required by payers in a bid to control costs.
“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 Jack Resneck, Jr., M.D., said in a release accompanying the survey. “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.”
Specifically, 86% of respondents told the professional organization that prior authorization “sometimes, often or always” leads to higher overall utilization of healthcare resources.
Just under two-thirds said that prior authorization has led to ineffective initial treatments, while 62% pointed to additional office visits and 46% to immediate care and/or emergency room visits resulting from the practice.
Eighty-nine percent of respondents said they believed that the prior authorization process has a “somewhat or significant negative impact” on patient clinical outcomes. A third said they have personally cared for a patient who had a serious adverse event that was caused by prior authorization requirements.
Also in question was the clinical validity of prior authorization criteria imposed by payers. Just under a third of respondents told the AMA that the criteria are “rarely” (27%) or “never” (4%) based on peer-reviewed evidence or guidelines from national medical specialty societies. Forty-three percent said criteria was “sometimes” based on evidence, while 14% and 1% said, respectively, that they were “often” or “always” based on evidence.
Often landing beside prior authorization’s clinical critiques are arguments that the process is time-consuming and mentally draining for clinicians.
Here, survey respondents said their practices complete an average of 45 prior authorizations per physician per week, comprising about 14 hours per week on average between physicians and their staff. Thirty-five percent of physicians have staff who work exclusively on handling prior authorization, respondents said.
Last week during a webinar discussion on rising clinician burnout, Resneck and U.S. Surgeon General Vivek Murthy, M.D., pointed the finger to prior authorization as a contributor to skyrocketing levels of burnout experienced by much of the nation’s clinical workforce.
“To be denied the care, often time-sensitive care, that a patient needs because of a bureaucratic process that often feels like it's set up to inhibit care and prevent expenditures rather than improve quality of care—that hurts patients and doctors,” Murthy said to Resneck during the webinar.
In late 2022 the Centers for Medicare and Medicaid Services proposed a rule with new streamlined prior authorization requirements for payers, which was quickly followed by calls for additional reforms from provider groups. Industry groups including the AMA, the American Hospital Association and the Medical Group Management Association have submitted public comments on the proposed rule. The public comment period closed on March 13.
"The AMA greatly appreciates Administrator Brooks-LaSure’s reform proposal and its focus on the role of payer decision-making and electronic information exchange in the prior authorization process,” Resneck said in a release linking to his organization’s public comments and additional recommendations on the proposed rule.