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AMA: Health Payers Lagging with Prior Authorization Reform

Prior authorization requirements and processes are still a burden on providers despite health payers agreeing to specific prior authorization reform last year.

Prior authorization reform

Source: Thinkstock

By Jacqueline LaPointe

- Health payers have not made meaningful progress with prior authorization reform, the American Medical Association (AMA) recently argued following the release of their new physician survey.

The national association recently surveyed 1,000 practicing physicians to gauge the healthcare industry’s progress with prior authorization reforms agreed upon in the “Consensus Statement on Improving the Prior Authorization Process.”

Released in January 2018, the Consensus Statement calls for prior authorization reforms based on five key areas:

  • Selective application of prior authorization requirements
  • Regular reviews of services and drugs subject to prior authorizations and appropriate volume adjustments
  • Increased transparency and communication between stakeholders regarding prior authorizations
  • Continuity of patient care
  • Implementation of automated prior authorization workflows and systems

Alongside the AMA, the American Hospital Association (AHA), America’s Health Insurance Plans (AHIP), American Pharmacists Association, Blue Cross Blue Shield Association, and Medical Group Management Association (MGMA) developed and agreed to implement the prior authorization reforms in response to provider challenges with the utilization management tool.

Prior authorizations have been a major thorn in the side of providers. A 2017 MGMA survey showed that 86  percent of providers reported an increase in prior authorization requirements that year, and a separate survey from the AMA also found 90 percent of providers agreed that prior authorizations delay care.

The payer and provider groups intended for the Consensus Statement to alleviate provider challenges with prior authorizations. But AMA’s latest survey shows that may not be the case. Over a year after the groups released the Consensus Statement, payers have yet to widely implement the reforms, the survey showed.

The survey found that the majority of physicians in the survey (88 and 86 percent, respectively) report that the number of prior authorizations required for prescription drugs and medical services increased over the last five years.

The survey also found health payers have stalled progress with implementing the other four prior authorization reforms, too. The survey found:

  • 8 percent of physicians report contracting with health plans that offer selective application of prior authorization requirements, or prior authorization requirement exemptions based on the provider’s performance and adherence to evidence-based medicine
  • 69 percent of physician still find it difficult to determine whether a prescription or service requires prior authorization
  • 85 percent of physicians say prior authorizations still interfere with continuity of care
  • Majority of physicians agree phone and fax are still the primary method for completing prior authorizations, and only 21 percent report their EHR systems offer electronic prior authorizations for prescription drugs

“Physicians follow insurance protocols for prior authorization that require faxing recurring paperwork, multiple phone calls and hours spent on hold. At the same time, patients’ lives can hang in the balance until health plans decide if needed care will qualify for insurance coverage,” Barbara L. McAneny, MD, AMA’s President, stated in an official press release.

“In previously released AMA survey results, more than a quarter of physicians reported that insurers’ extended business decision-making process led to serious adverse events for waiting patients, such as a hospitalization or disability. The time is now to fix prior authorization.”

The AMA highlighted state efforts to fix the prior authorization process. Policymakers introduced 84 patient protection bills in 32 states in the last year to mitigate the negative impact of prior authorizations, particularly on patient care.

Notably, some of the bills attempt to eliminate prior authorization requirements and access challenges for lifesaving treatments, such as medications used to treat opioid use disorder. For example, policymakers in Pennsylvania and Vermont are working with local payers to remove prior authorizations for opioid use disorder treatments.

Eliminating prior authorization requirements for medications used to treat patients with opioid use disorder is a top priority for the AMA.

The association called on attorneys general across the nation in February 2017 to reform prior authorizations for medication-assisted treatment for opioid use disorder after New York reached settlements with Cigna and Anthem over their requirements.

“There is no reason for insurers to use prior authorization for medications to treat opioid use disorders when patients’ lives hang in the balance,” said McAneny. “The AMA urges all health insurers to join with the medical community to enact vital legislation that is an important step in reversing the opioid epidemic.”


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