Actions speak louder than words, and an AMA survey of physicians shows (PDF) that health plans have failed to take meaningful action on the commitments they made to change the way they handle aspects of prior authorization that hurt patients and waste physicians’ time.
In 2018, the AMA, the insurer trade group AHIP, Blue Cross Blue Shield Association, American Hospital Association, American Pharmacists Association and Medical Group Management Association released a “Consensus Statement on Improving the Prior Authorization Process” (PDF).
But nearly six years later, when the AMA surveyed 1,000 physicians about prior authorization, doctors reported that not enough has changed. The AMA is fixing prior authorization by challenging insurance companies to eliminate care delays, patient harms and practice hassles.
Here is what physicians had to say about the burdens that they and their patients still face in the five core areas that the consensus statement sought to address.
Selectively applying prior authorization: Just 8% of physicians reported that they contracted with health plans that offer programs that exempt them from prior authorization through a program like gold carding, which excuses physicians from the process when they’ve shown they consistently get approval for treatments and medications they prescribe.
Prior authorization program review and volume adjustment: More than 80% of physicians reported that the number of prior authorizations required for prescription medications (83%) and medical services (82%) has risen over the past five years. Meanwhile, 55% of physicians reported that prior authorization is at least sometimes required for a generic medication.
Transparency and communication regarding prior authorization: Nearly two-thirds of physicians reported that it is difficult to determine whether a prescription medication requires prior auth, while 59% said that’s true of a medical service. Nearly one in three physicians (29%) said that prior authorization requirement information provided in their EHR or electronic prescribing system is rarely or never accurate.
Continuity of patient care: Almost 90% of physicians reported that prior authorization interferes with continuity of care. Nearly three in five (59%) reported that prior authorization at least sometimes destabilizes a patient whose condition was previously stabilized on a specific treatment plan.
Automation to improve transparency and efficiency: Just 23% of physicians reported that their EHR system offers electronic prior authorization for prescription medications. Physicians said the phone was the most common method used to complete prior authorizations.
How payers compare on prior auth
Despite that 2018 consensus agreement, payers have largely dragged their feet on improving the prior authorization process.
Last fall, UnitedHealthcare announced plans to start eliminating prior authorization requirements for a number of procedure codes, which the insurer said accounted for nearly 20% of its overall prior authorization volume. UnitedHealthcare also announced it would implement a gold card program in 2024 to let those who qualify follow a “simple administrative notification process for most procedure codes” instead of prior authorization.
Meanwhile, Cigna announced last year that it would remove nearly 25% of medical services from its prior authorization requirements.
The AMA physician survey shows how sorely needed those changes and others are needed.
When asked to describe the burden associated with prior authorization in their practice for specific health plans, more than half of physicians said the burden is “high” or “extremely high.” Here’s the breakdown by payer:
- UnitedHealthcare—62%.
- Humana—60%.
- Cigna—55%.
- Aetna—54%.
- Blue Cross Blue Shield—52%.
- Anthem/Elevance—55%.
Learn more by exploring this video collection of AMA member physicians’ prior authorization horror stories.
Fighting for positive changes
With the insurance industry slow to implement comprehensive prior authorization reforms on their own, the AMA strongly supports the Improving Seniors’ Timely Access to Care Act of 2024, bipartisan and bicameral federal legislation that would reform prior authorization procedures in Medicare Advantage.
“Because insurers will not change their ways despite their rhetoric, lawmakers have an important opportunity to rein in excessive prior authorization requirements and unnecessary administrative obstacles between Medicare Advantage patients and evidence-based treatments,” said AMA President Bruce A. Scott, MD.
The AMA also is pressing for critical national and state-level prior authorization reforms that must be made to improve prior authorization, including gold-carding programs, making prior authorization valid for the length of treatment for those with chronic conditions, requiring that new health plans honor a previous health plan’s prior authorization for a minimum of 90 days, and more.
Patients, doctors and employers can learn more about reform efforts and share their personal experiences with prior authorization at FixPriorAuth.org.
Fighting for Physicians
Get updates on how the AMA is fighting for physicians on critical issues—delivered to your inbox.
