American Medical Association: Payers are failing at prior authorization reform

The American Medical Association criticized the health insurance industry May 24 for what it says are slow or ineffective prior authorization reforms implemented over the last four years, despite payers agreeing to changes aimed at improving care access and efficiency.

A 2018 consensus agreement outlined five key prior authorization reforms agreed upon between groups representing the nation's largest payers and providers. Now the AMA says results from a December 2021 1,000-physician survey call into question whether payers are capable of voluntarily implementing prior authorization reforms.

"Waiting on a health plan to authorize necessary medical treatment is too often a hazard to patient health," President Gerald Harmon, MD, said. "Authorization controls that do not prioritize patient access to timely, optimal care can lead to serious adverse consequences for waiting patients, such as a hospitalization, disability, or death. Comprehensive reform is needed now to stem the heavy toll that continues to mount without effective action."

Five survey takeaways:

  1. The consensus agreement said prior authorization requirements should be selectively applied to physicians based on how well they follow evidence-based guidelines and quality measures. The survey found only 9 percent of physicians contracted with health plans that actually offer programs that selectively apply prior authorization requirements.

  2. The consensus agreement said drugs and services requiring prior authorization should receive regular payer review to remove items that have low variation in use or denial rates. In the survey, 84 percent of physicians said the quantity of drugs and services requiring prior authorization has increased.

  3. The consensus agreement said payers should "encourage transparency and easy accessibility of prior authorization requirements, criteria, rationale, and program changes." In the survey, 65 percent of physicians said it's difficult to determine whether a drug requires prior authorization, and 62 percent said it's difficult to determine whether a medical service requires prior authorization.

  4. The consensus agreement said payers should decrease disruptions for needed care and repetitive prior authorization requirements, but the survey found 88 percent of physicians believe prior authorization interferes with their ability to continue providing care.

  5. The consensus agreement said there will be actions taken to implement more standards around electronic transactions for prior authorizations, but only 26 percent of physicians say their EHR systems allow electronic prior authorizations for prescriptions.

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