CHICAGO—At the height of the COVID-19 pandemic, physicians reported being bedeviled by unnecessary, bureaucratic obstacles that the health insurance industry pledged to reduce three years ago. The data highlights the urgent need for new bipartisan legislation introduced this week in the House, the Improving Seniors’ Timely Access to Care Act.

An AMA-conducted survey shows that physicians are running into roadblocks because of prior authorization, or the process of requiring health care professionals to obtain advance approval from health plans before a prescription medication or medical service is delivered to the patient.

The 1,000 practicing physicians surveyed in December 2020—when new COVID-19 cases were soaring — reported that prior authorization was widespread.  Eighty-three percent of respondents indicated that prior authorizations for prescription medications and medical services have increased over the past five years. Along with this increased volume of requirements, most physicians reported a continued lack of transparency in prior authorization programs, with a majority of physicians stating that it is difficult to determine whether a prescription medication (68 percent) or medical service (58 percent) requires prior authorization. An overwhelming majority (87 percent) of physicians also reported that prior authorization interferes with continuity of care.

This grim reality persists despite the fact that three years ago, the AMA and other large health organizations signed a consensus statement that was intended to improve the prior authorization process. The AMA, along with the American Hospital Association, America’s Health Insurance Plans, American Pharmacists Association, Blue Cross Blue Shield Association and the Medical Group Management Association, agreed to reforms needed to reduce prior authorization burdens and enhance patient-centered care.

“You would think insurers would ease bureaucratic demands throughout a pandemic to ensure patients’ access to timely, medically necessary care. Sadly, you would be wrong,” said AMA President Susan R. Bailey, M.D. 

Given the insurance industry’s lack of progress in voluntarily reducing the burdens of prior authorization agreed to in the consensus statement, the AMA is calling on Congress to remedy the problem. The Improving Seniors’ Timely Access to Care Act (HR 3173) takes direct aim at the insurance industry’s foot-dragging and would codify much of the consensus statement.

This bipartisan legislation would require Medicare Advantage (MA) plans to implement a streamlined electronic prior authorization process that complies with technical standards developed by the Department of Health and Human Services, in consultation with relevant stakeholders. In addition, the bill would require increased transparency for beneficiaries and providers, as well as enhance oversight by the Centers for Medicare & Medicaid Services on the processes used for prior authorization. Moreover, to ensure that routinely approved care and treatments are not subjected to unnecessary delays, the program would provide for real-time decisions by an MA plan with respect to certain prior authorization requests.  Importantly, the bill would also require MA plans to meet beneficiary protection standards, such as ensuring continuity of care when patients change plans. 

The AMA strongly supports the Improving Seniors’ Timely Access to Care Act. The data released today build upon previously published survey results that underscore the significant patient and practice burdens associated with prior authorization and the critical need for legislative reform.

“There is no room in the patient-physician relationship for insurance-industry barriers. The AMA is dedicated to simplifying and right-sizing prior authorization so physicians can properly provide care and patients can receive the timely treatment they deserve,” Bailey said. “This legislation is a win-win for patients and physicians.”