Just about any physician you talk to these days can tell you prior-authorization (PA) horror stories. In my specialty of dermatology, I knew insurers had hit a new low when getting approval even for cheap, generic steroid creams widely prescribed for six decades began to require several days of faxes, phone calls and appeals before patients could pick up their medication.
More and more of my patients with chronic conditions who had found successful therapies also began to face repeated PA hurdles when their health plan changed formularies, disrupting their care.
What a colossal waste of time, not only for my overburdened office staff who must jump through so many hoops from insurance companies—but, more importantly, for my patients, who often suffer real health consequences due to unnecessary delays. It’s no wonder doctors and patients alike are calling for major changes to the prior-authorization process.
The AMA has long made reforming the onerous prior-authorization process a focal point of its efforts to remove obstacles that interfere with patient care. And we included it as one of the five core elements in the AMA Recovery Plan for America’s Physicians introduced in June, and at our grassroots advocacy site, fixpriorauth.org.
Action at the federal level
But after years of ever-increasing PA demands and ever-growing risks to patients, good news is finally on the horizon. A bill that passed the House of Representatives this week—the “Improving Seniors’ Access to Timely Care Act of 2022” (H.R. 3173)—enjoys strong bipartisan support. This legislation was championed by the AMA and now we ask you to join us in urging the Senate to pass this important bill.
Among other requirements, H.R. 3173 will require Medicare Advantage plans to implement electronic prior auth programs, establish real-time approval for many items and services, and transparently publish just how often they require PA and how frequently they deny them.
This bill represents real progress in reforming prior authorization nationally. But it’s far from the only movement underway that can help us rein in what has become one of the most troublesome aspects of modern medicine.
So-called gold card laws, like the one that took effect in Texas in January, provide a pathway for many doctors to bypass the prior-authorization process altogether. The vast majority of physicians are practicing evidence-based medicine and shouldn’t be subjected to PA at all.
A gold card provides physicians with an opportunity for continuous exemption from prior authorization based on their proven ability to secure a high rate of approvals for previous requests. In Texas, physicians who achieve a 90% prior-authorization rate on certain services or medications will soon no longer need to complete prior-auth requests for those services, although implementation is still underway. Other states are looking closely at this new Texas law and how it may expedite PA for physicians and staff at home.
Increasing demands of prior auth
The unchecked growth of prior-authorization requirements by health plans, and their reliance on proprietary, undisclosed clinical criteria in making coverage decisions, continue to make a bad situation worse—and emphasizes the need for gold-card laws and other reforms. Because the prior-authorization criteria developed by insurers are purposely opaque, physicians are typically unaware of precisely what type of information an insurer is seeking, and as a result must submit multiple explanations.
Physicians expect challenges when prescribing brand new, expensive drugs, but prior authorization now widely applies to treatments that are standard of care without lower-cost substitutes. Prior auth must be eliminated altogether for the majority of well-established medications and procedures with low final denial rates.
All of that extra paperwork takes time and resources. And when initial denials are issued, additional time and resources are diverted from patient care to appeal and reverse inappropriate decisions. Physicians often find that the person at the other end of those appeal calls isn’t from the same specialty—or isn’t a physician at all—and in many cases doesn’t know anything about the condition being treated or the medication or procedure being sought. Sometimes we receive suggested alternatives that are completely inappropriate and would cause patient harm. Spending time away from our patients trying to explain appropriate treatment rationales to health plan employees is a frustrating waste of time.
Evidence of the damage inflicted by excessive prior authorization can be found in this 2021 AMA survey (PDF), in which 93% of physicians said that prior authorization had delayed access to care their patients needed—and 82% said the process had led patients to abandon treatment. The average physician faced 41 PA requests per week, taking them and their teams about 13 hours to complete. We also know that many patients give up when their prescriptions are initially rejected at the pharmacy, worsening their chronic illnesses and ultimately increasing health care costs.
Our AMA continues to support physicians with a broad range of prior-authorization reform initiatives, and we will continue to aggressively advocate for reforms so that our patients can get the evidence-based treatments they need.
Benefits all around
Reducing the PA burden also helps accomplish another crucial element of the AMA Recovery Plan for America’s Physicians, which targets burnout reduction among the physician workforce and emphasizes the need to support physician wellness. Physicians have been holding together a health care system stretched far too thin in recent years, and it’s time that we help them get back to what drew them to medicine in the first place: taking great care of patients.
Eliminating excessive prior-authorization requirements means stripping away an exhausting burden and an obstacle to optimal patient care, and our AMA is doubling down on this important mission as the physician’s powerful ally in care. Contact your senator today to join us in advocating for this important legislation—an important step to reforming prior authorization.
