AMA says health insurance industry failing on prior auth reform

The American Medical Association says that despite insurance industry promises to reform and improve prior authorizations, little effort has been made to do so.

This comes despite evidence that insurer-imposed authorizations can be hazardous and burdensome to patient-centered care.

In January 2018, the AMA and other national organizations representing pharmacists, medical groups, hospitals and health insurers signed a consensus statement outlining a shared commitment to five key reforms for the prior authorization process. Taken together, the five reforms promote safe, timely, and affordable access to evidence-based care for patients; enhanced efficiency; and reduced administrative burdens.

But findings from the AMA physician survey conducted in December 2021 show that little progress has been made, and the AMA questions whether the health insurance industry can be relied upon to voluntarily expedite comprehensive reform to the cumbersome prior authorization process that delays and disrupts patient-centric care.

“Waiting on a health plan to authorize necessary medical treatment is too often a hazard to patient health,” said AMA President Gerald E. Harmon, MD, in a statement. “Authorization controls that do not prioritize patient access to timely, optimal care can lead to serious adverse consequences for waiting patients, such as a hospitalization, disability, or death. Comprehensive reform is needed now to stem the heavy toll that continues to mount without effective action.”

The AMA survey examined the experiences of more than 1,000 practicing physicians with each of the five prior authorization reforms in the consensus statement and illustrates that the goal of comprehensive reform is far from complete.

Selectively apply requirements
Prior authorization requirements should be selectively applied to physicians based on demonstrated adherence to evidence-based guidelines and quality measures, according to the consensus statement. Survey results show fewer than one out of ten physicians (9%) contracted with health plans that offer programs that selectively apply prior authorization requirements.

Adjust the volume of requirements
The list of drugs and services that require prior authorization should be regularly reviewed by insurers to remove items that show "low variation in utilization or low prior authorization denial rates," according to the consensus statement. Most physicians (84%) reported the number of drugs requiring prior authorization has increased. An equal majority of physicians (84%) reported the number of medical services needing prior authorization has grown.

Make rules clear and accessible
Insurers should "encourage transparency and easy accessibility of prior authorization requirements, criteria, rationale, and program changes," the consensus statement reads. Almost two-thirds of physicians (65%) reported it is difficult to determine whether a drug requires prior authorization. Slightly fewer physicians (62%) reported it is difficult to determine whether a medical service requires prior authorization.

Support continuity of patient care
Insurers should “minimize disruptions in needed treatment,” including “minimizing repetitive prior authorization requirements,” as stated in the consensus statement. An overwhelming majority of physicians (88%) reported that prior authorization interferes with continuity of care.

Accelerate the use of automation
Efforts should be made to speed the adoption of existing national standards for electronic transactions for prior authorizations, according to the consensus statement. Only about one out of four (26%) physicians reported that their electronic health record system offers electronic prior authorization for prescription medications.

As a result of these failings, the AMA and other physician organizations are calling on Congress to fix the problem through the Improving Seniors’ Timely Access to Care Act (HR 3173 / S 3018), which would codify much of the consensus statement.