Dive Brief:
- While insurers impose prior authorization requirements to manage cost and quality control, most physicians say the rules cause unnecessary waste and can lead to avoidable harm for patients, according to a survey out Monday from the American Medical Association.
- Over a third of physicians said the requirements led to a serious adverse event for one of their patients, such as hospitalization, permanent impairment or death, the survey found.
- About 60% said the requirements led to resources being diverted to ineffective initial treatments or additional office visits, and almost half said they lead patients to seek urgent or emergency care.
Dive Insight:
Prior authorization requirements have long been criticized for putting additional administrative requirements on physicians and even leading to burnout. The AMA survey found physicians believe the rules are also impacting health outcomes, and comes as the CMS works to finalize a new rule on the policies.
While insurers have said the policies reflect evidence-based medicine, physicians disagree and said they feel a lack of transparency in the payer approval process and that their clinical authority and expertise is diminished, according to the AMA report.
Almost 90% of respondents said the rules had a negative impact on patient clinical outcomes, the survey, which included responses from 1,000 physicians collected in December, found.
At the end of last year the CMS proposed a new rule intending to streamline prior authorizations by requiring certain payers, including Medicare Advantage plans, to use an electronic process and respond to requests more quickly, with comments on the rule due Monday.
The AMA supports the proposals, though offered recommendations “particularly around the rule’s scope, payer transparency, and processing time requirements,” it said in a release.
“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,” AMA President Jack Resneck said in the release.
Other provider groups like the American Medical Group Association support new policies to reduce the use of prior authorization, though AMGA said in a statement the new rules need to exempt more providers from the need to use it.
AMGA also wants the CMS to require insurers to respond in a much shorter time frame, and deem requests approved if they miss deadlines.
The American Hospital Association urged the agency to finalize the prior authorization rule in a Monday statement, though said the CMS should adequately enforce and monitor the requirements and test any electronic standards before requiring their adoption.
Other major impacts of the requirements cited by physicians in the AMA survey include delayed care and disrupted care, as patients often abandon treatment when faced with prior authorization challenges. Physicians also said the rules impeded their patients’ own job performance.
The survey also asked physicians how the rules impact their daily workloads, finding practices complete 45 prior authorizations per physician per week on average.
Some 35% of physicians said they have staff that exclusively work on prior authorizations.
