The time-wasting, care-delaying, insurance company cost-control process known as prior authorization has gone from a rarely employed tool to discourage use of extremely pricey interventions to a form of utilization management that comes as naturally to payers as breathing does to the rest of us.
Prior authorization is overused, and existing processes present significant administrative and clinical concerns. That is why fixing prior authorization is a critical component of the AMA Recovery Plan for America’s Physicians.
Prior authorization is a multifaceted problem that needs to be tackled from numerous angles. High on the hit list are the sluggish response times, an overwhelming and increasing volume of requirements, inadequate peer-to-peer reviews and more. As the physician’s powerful ally in health care, the AMA is tackling prior authorization with research, practice tools and reform resources.
In this fifth installment of an AMA series on fixing prior authorization, we take a look at how prior authorization disrupts continuity of care and what that means to patients and physicians. We explore what steps must be taken to rightsize prior authorization to improve continuity of care, lay out what changes have already happened and which ones still need to be made.
What’s the problem?
Whether it’s a patient switching health plans or an insurer frequently requiring prior authorization for medications or other treatments on which a patient has been stable for years, prior authorization disrupts patient care and can result in relapses, unnecessary pain and suffering, hospitalization and more. For physicians, this type of prior authorization also creates additional administrative burdens.
“Dealing with prior authorization is just a disaster both for physicians, but more so for the patient. They’re put in situations where they are not sure whether they are going to get their medication, they’re not sure whether they are going to be able to have a test,” cardiologist Jerry Kennett, MD, said in a moving video that is part of a collection of AMA member physicians’ sharing their awful experiences with prior authorization in practice.
Take for instance what happened to a patient with opioid use disorder who was cared for by Nebraska addiction psychiatrist Alëna A. Balasanova, MD. The man was stabilized on a medication for opioid use disorder.
“I wrote his prescription to go pick up at the pharmacy, which was promptly denied because he required prior authorization for this generic medication,” Dr. Balasanova said. “I tried first calling and they said: ‘Well, no for this medication you can’t do it over the phone. You have to fill out the paperwork and send it to us.’ So, I filled out the paperwork. I sent it to them by fax. They said: ‘Well, you should hear something within 48 hours,” Dr. Balasanova said in another heartbreaking AMA video.
Without his medication for opioid use disorder, the patient relapsed.
“It’s terrifying to be thinking about what’s happening with my patients when there’s these entities that are literally playing with their lives,” Dr. Balasanova said.
New Jersey family physician Mary Campagnolo, MD, had a patient with type 2 diabetes whose condition was well-controlled with a long-acting formulation of metformin. Then the patient switched to a new health plan.
“They required her to go through prior authorization for a medication she’d been on for years. Basically, they were asking her to go back on a generic metformin, which had contributed to significant gastrointestinal disruption. They were asking her to make herself sick in order for us to justify her need that particular medication,” Dr. Campagnolo said in an AMA video. “It’s really unethical for us to be forced to make somebody become sick by taking a medicine that hasn’t worked for them in order to justify the other medication that we’re seeking.”
One patient, Candace, told the story of how her health coverage changed when her husband took a new job. The new health plan made her go through a prior authorization process for a medication she had been taking that had been working for her.
“I missed doses. My family life suffered. They made me lose quality of life,” Candace explained in another AMA video on prior authorization.
In fact, one-third of the 1,001 physicians surveyed (PDF) by the AMA reported that prior authorization has led to a serious adverse event for a patient in their care. More specifically, the AMA survey found that these shares of the physician respondents reported that prior authorization led to:
- A patient’s hospitalization—25%.
- A life-threatening event or one that required intervention to prevent permanent impairment or damage—19%.
- A patient’s disability or permanent bodily damage, congenital anomaly or birth defect, or death—9%.
Meanwhile, 89% of doctors reported that prior authorization interfered with continuity of care.
What are the fixes?
There are several ways to prevent scenarios such as Candace’s and the ones that Drs. Balasanova and Campagnolo described.
First, if a patient enrolls in a new health plan and their condition is stabilized on a particular treatment that the new insurer requires prior authorization or step-therapy protocols for, the health plan should allow the patient to continue on their current ongoing treatment while prior authorization approvals or step-therapy overrides are obtained.
“Utilization-review entitles should offer a minimum of a 60-day grace period for any step-therapy or prior authorization protocols for patients who are already stabilized on a particular treatment upon enrollment in the plan,” according to the AMA’s “Prior Authorization and Utilization Reform Principles” (PDF). “During this period, any medical treatment or drug regimen should not be interrupted while the utilization management requirements … are addressed.”
That document emerged from an AMA-convened workgroup with 16 other state and specialty medical societies, national provider associations and patient representatives. It includes 21 principles covering five main areas, including continuity of care.
The principles also say that:
- If a drug or medical service is removed from a plan’s formulary or is subject to new coverage restrictions after the beneficiary enrollment period has ended, it should be covered without restrictions for the rest of the benefit year.
- A prior authorization approval should be valid for the duration of the prescribed or ordered course of treatment.
- Patients should not be required to repeat step-therapy protocols or retry therapies that failed before the payer qualifies them for coverage of a current, effective therapy.
What progress has been made?
Georgia, Kentucky, Louisiana, Michigan, Minnesota, Montana, New Jersey, Ohio, Oregon, Tennessee Virginia, Texas, Washington and Washington, D.C., have all passed laws (PDF) pertaining to how long a prior authorization must be honored. The laws vary.
In Tennessee, a law set to take effect in 2025 requires that carriers honor approved prior authorizations for at the initial 90 days of an enrollee’s coverage under a new health benefit plan.
Meanwhile, in Texas, health plans are not allowed to require a patient to undergo more than one prior authorization annually for a prescription drug prescribed to treat an autoimmune disease, hemophilia or Von Willebrand disease.
And in Washington, D.C. the law requires that prior authorization be valid for at least one year or for the course of a treatment, even if the physician changes the dosage. Chronic condition prior authorization is valid for as long as it is medically reasonable and necessary to avoid disruption in care. The law also says a new insurer must honor a prior authorization for 60 days.
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Georgia’s law, among other things says that a new plan must honor an old plan’s prior authorization for 30 days, while in Illinois the law requires a 90-day period when a patient changes plans.
Even though there are a number of standards that address continuity of care, there still needs to be “additional efforts to minimize the burdens and patient care disruptions associated with prior authorization,” says a 2018 consensus statement (PDF) the AMA crafted with the Blue Cross Blue Shield Association, Medical Group Management Association, the insurer trade group AHIP and others.
To further that goal, they agreed to:
- Encourage sufficient protections for continuity of care during a transition period for patients undergoing an active course of treatment when there is a formulary or treatment coverage change or change of health plan that may disrupt their current course of treatment.
- Support continuity of care for medical services and prescription medications for patients on appropriate, chronic, stable therapy through minimizing repetitive prior authorization requirements.
- Improve communication between health care providers, health plans and patients to facilitate continuity of care and minimize disruptions in needed treatment.
What’s the AMA still pushing for?
While the consensus statement has been in place since 2018 and a number of states have passed laws in this area of prior authorization, there is still much to be done. Payers have largely dragged their feet on changing policies that will give patients better continuity of care and more states and the federal government can pass laws enshrining protections.
To help achieve a system that provides that continuity of care, the AMA continues to push for these reforms at the federal and state levels:
- Making authorization valid for at least one year even if a dose changes.
- Making prior authorization valid for the length of treatment for those with chronic conditions.
- Requiring a new health plan to honor a patient’s prior authorization for a minimum of 90 days.
“We bring a lot of resources that we offer to those state medical associations doing that work and to the legislators who want to partner with on this. … We have charts about state law across the country, draft testimony that can help physicians prepare when they're going to go talk about their experiences. We actually have attorneys and others who can do real-time bill analysis as the language develops,” AMA Immediate Past President Jack Resneck Jr., MD, said during an “AMA Update” video.
“The momentum is building,” he said. “We're working on this across the country so that every patient and every physician gets the benefit of rightsizing prior auth.
How can patients and physicians help?
An AMA model bill (PDF) can help physicians get started on advocating change in their own state legislatures. Patients, doctors and employers can learn more about reform efforts and share their personal experiences with prior authorization at FixPriorAuth.org.
