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What are the outcomes of prior authorization patients? How do insurance companies use AI? How does prior authorization work? Who is responsible for getting pre-authorization?
AMA President Bruce A. Scott, MD, shares key takeaways from the AMA's recent prior auth survey, discusses physicians' concerns about prior authorization in health care, how prior authorization negatively impacts employers by reducing employee health and productivity. AMA Chief Experience Officer Todd Unger hosts.
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Speaker
- Bruce A. Scott, MD, president, American Medical Association
Transcript
Dr. Scott: Over 90% of the physicians say that they believe that the prior authorization process harms their patients, that it delays care, that it denies care.
Unger: Hello and welcome to the AMA Update video and podcast. Today, we're talking about the AMA's latest survey on prior authorization and its impact on physicians and patients. Joining us to discuss the key takeaways is AMA President Dr. Bruce Scott in Louisville, Kentucky. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Scott, welcome back.
Dr. Scott: Well, Thank you very much. It's a pleasure to be here with you.
Unger: Well, prior auth is a huge topic of conversation for everyone. And one of the most interesting findings in this year's survey has to do with the role of AI in prior authorization. Dr. Scott, let's start with that. What can you tell us?
Dr. Scott: Well, it's interesting, Todd. Physicians are very hopeful that AI will actually reduce the administrative burden that we face to give us more time to do what we all went into medicine to do, to take care of patients. And yet, in the survey, three in five of the physicians surveyed say that they're actually fearful that the insurance companies will use AI to actually increase prior authorization, to increase the denials.
They say that they fear that the health plans will use AI as another way to question medical judgment, to delay care and to deny care, and at the end of the day, harm the patients. The AMA strongly believes that medical decisions should be made by physicians with their patients, not by computer algorithms.
Unger: Well, our survey also looked extensively at the burden of prior authorization on patients, some of which you're referring to right there. What were some of the findings that stood out to you?
Dr. Scott: Well, it's amazing that over 90% of the physicians say that they believe that the prior authorization process harms their patients, that it delays care, that it denies care. And they went even further to say in 80% of the cases, that it leads to patients abandoning care.
Now the patient goes to the pharmacy, for example, and they find out that the prescription that was sent in requires prior authorization. So, unfortunately, in a lot of cases, they leave without the prescription, so they don't get the care, the medicine that the physician recommended.
And the survey goes on to say that nearly one in four of the physicians say that this whole process has led to serious adverse events. Now, what they mean by that is hospitalizations, permanent impairment, and even death for one or more of their patients. So this is harming patients in general.
But the other thing I would say is that for every patient, it adds stress. You go to your doctor, your doctor examines you, and you develop a plan and you walk out thinking what's going to happen. And then you got to wait for your insurance company to approve it. And that just adds unnecessary anxiety and stress for the patients.
Unger: You're talking about stress for patients and potential harms that come, especially if you have to abandon a particular course of medication. But we also know that prior authorization has significant impact on physicians as well. What did the survey have to say about that?
Dr. Scott: Well, you're exactly right. And as a practicing physician myself, I live this every day. The survey found that the average physician is filling out 39 prior authorization requests on average a week. That's wasting about 13 hours of physician and our staff time. Again, time that could be better spent taking care of patients.
And the result of this is frustration. You sit down with the patient, you do a thorough exam, you take a history, you talk to them, you come up with a plan, and then you got to get on the phone and justify it with a person at a health plan. It leads to frustration for physicians. And actually, in the survey, over 90% of physicians said that it is a major factor in contributing to physician burnout. So there you go. It's frustrating for the doctors, it wastes our time and it harms patients.
Unger: Now, Dr. Scott, in my conversations with you and your speeches, you often cite firsthand stories about what you see in your own practice regarding issues with prior authorization. Is there a recent experience you can tell us about?
Dr. Scott: I can almost tell you a story a week, Todd. A recent one, and I know all of your listeners are not detailed on anatomy, but I had a patient the other day who had a growth identified in his piriform sinus, and this is down in the neck. Yet, the insurance company denied the prior authorization for the CT scan because he had not been on a nasal spray.
So they were obviously thinking that the piriform sinus was in the nose. And so I get on the phone and I'm talking to this person, obviously not a physician. And I say to them, I said, you do realize that the piriform sinus is in the throat. So I'm not sure how a nasal spray is going to help.
Well, there's silence on the other end of the phone, as it becomes clear that this person who's making the insurance company's decision doesn't even know the anatomy. Yet, they're going to make the decision. This makes no sense at all.
Unger: Hard to argue with that. And the fact that you have so many stories about just this kind of problem, it's pretty distressing. One aspect of prior authorization that we don't talk about as much is its impact on employers. What does that look like and why is that important?
Dr. Scott: Well, that's an interesting perspective. Employers in this country pay the majority of the premiums for the health plans. And yet, sometimes they don't necessarily know that their employees are actually having trouble getting the care that they're paying for. And the reason that employers are invested in this is because they want their employees to be healthy. They want them to be productive.
And if instead of being at work and productive, they're waiting to see if the insurance company is going to approve the care that they need, or waiting for the phone call from the insurance company to find out whether something's going to be covered or not, that reduces the productivity. So actually, there's an opportunity for the employers to help.
Employees should talk to their HR benefits group. In some cases, they can be an advocate for the patient who needs to get through the prior authorization burden. And then if the HR people become aware of the administrative hassles that a health plan is causing, perhaps when it comes time to decide which health plan you're going to contract with the next year, they may have a different opinion.
And then we can put pressure on the health plans to actually provide the care that the employers are paying for. At the end of the day, you could say that the insurance companies are putting their profit ahead of the productivity of the people who are paying the bills. And that's where the employers could potentially become advocates, along with the AMA and physician groups, to try to correct this broken prior authorization system.
Unger: That's a very smart angle and different from what I've heard. But it makes a lot of sense. Clearly, the survey results, many of the conversations that we have, it's very clear that this process needs to be fixed. Both Cigna and UnitedHealthcare have announced that they intend to reduce the burden of prior authorization. What's your perspective on that?
Dr. Scott: Well, first of all, let me say that the AMA is happy to work with any health plan that wants to reduce the burden of prior authorization. That said, when we hear that they want to reduce the burden, the first question that comes to my mind is, they want to reduce the burden on who? On physicians and patients or a burden on themselves?
And let me be clear, insurance companies using AI to more rapidly deny more and more prior authorization requests, that's not the reform that the AMA and physicians are looking for. What we want to see is reform that reduces the amount of prior authorizations, that leads to increased transparency, that continues continuity of care, that makes sure that the people who are making the decision.
And note, I said the people making the decision are qualified physicians to make the decision. Now, it's interesting, because we've heard this from the insurance companies before. In fact, the AMA sat down with the insurance companies in 2018 and came up with a consensus statement that would do exactly the things I just talked about—reduce prior authorization, increase transparency.
And yet, in the survey just recently completed, 75% of the physicians say that prior authorization is getting worse, not better, even though it's been seven years since the consensus statement. So we welcome the opportunity to work with the health plans. And I would tell you that some of the health plans are getting it right.
I was on a panel discussion recently. And the individual from a particular insurance company said that they're using AI only to approve prior authorization. Now, that makes sense because that's approving what the physician and the patient have already said is in their best interest. But the converse doesn't make sense. In fact, we're already seeing state legislators step in and say that that's unacceptable.
Unger: That's great perspective. Dr. Scott, fixing prior authorization is one of the AMA's top priorities. And we're continuing to push for change on every front. Can you talk a little bit more about the work that we're doing?
Dr. Scott: Absolutely, we began in 2024, really pushing hard, going directly to CMS, the Center for Medicare and Medicaid Services. And we got them to implement a number of changes. And since then, we've been working with the legislature to try to codify these changes and expand upon them.
And on a federal level, I was really excited at the end of the year because we had bipartisan support for legislation that would do exactly that. Unfortunately, it was left on the cutting room floor when they passed the continuing resolution at the end of the year. But we're pushing to get that reintroduced. And there is bipartisan support for this, so we're pretty hopeful.
Then, in addition to that, on a state level, we're working with the state medical associations all across the U.S. Right now, there are over 100 bills pending in state legislation about prior authorization to try to do exactly those things, of reduce the amount of services that require prior authorization, to increase transparency, and in some cases, to try to gather more information about exactly how the health plans are using prior authorization and how it's harming our patients.
Unger: Dr. Scott, thank you so much for joining us and for all your advocacy on this important issue. To see all the results of the AMA survey, be sure to check out the link in the episode description. And to support the AMA's ongoing research efforts, become an AMA member at ama-assn.org/join.
That wraps up today's episode. We'll be back soon with another segment. Be sure to subscribe for new episodes and find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us today. Please take care.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
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