Medical Groups Unite, Call for Prior Authorization Reform

Prior authorization adds an administrative burden for provider practices, and can delay the initiation of treatment for patients. The process can involve lengthy phone conversations with insurance companies and attempts to understand nontransparent rules. Physicians are often left in the dark as to which therapies or devices will be covered, which can result in high denial rates.

In a recent Internet-based survey of 1000 physicians (40% primary care physicians, 60% specialists) conducted by the American Medical Association (AMA), the majority of respondents indicated that the burden associated with prior au­thorizations was extremely high (Figure).¹ In addition, 64% of respondents reported that they do not have staff members who work exclusively on prior authorizations, 44% reported that the prior authorization often or always delays access to necessary care, 23% reported completing more than 40 prior authorizations in the past week, and 22% reported that it took more than 20 hours to process prior authorizations in the past week.

In January 2017, the AMA and 16 other healthcare organizations (Table), which represent physicians, medical groups, hospitals, pharmacists, and patients, announced that they had formed a coalition to help streamline the prior authorization process for medical tests, procedures, devices, and drugs to reduce administrative waste and save time.² This coalition has developed a comprehensive set of 21 principles designed to reshape the prior authorization process.^2,3 The principles have been grouped into 5 categories, including:

• Clinical validity
• Continuity of care
• Transparency and fairness
• Timely access and administrative efficiency
• Alternatives and exemptions.

Andrew W. Gurman, MD, President, AMA, Hollidaysburg, PA, stressed the importance of addressing the undue burden that is currently placed on medical practices.

“Strict or bureaucratic oversight programs for drug or medical treatments have delayed access to necessary care, wasted limited health care resources and antagonized patients and physicians alike. The AMA joins the other coalition organizations in urging health insurers and others to apply the reform principles and streamline requirements, lengthy assessments and inconsistent rules in current prior authorization programs,” he said in a press statement by the association.²

The formation of this coalition is just the latest step in ongoing advocacy efforts by the AMA and other organizations. In 2016, the AMA House of Delegates adopted an in-depth policy on the standardization and simplification of prior authorization.⁴ In addition, several states have already passed legislation aimed at protecting physicians and patients from the burden of overly complicated prior authorization processes, including laws requiring health plans to support electronic prior authorization submissions.⁵

As a member of the coalition, the American College of Rheumatology (ACR) is urging rheumatologists to continue to advocate for prior authorization reform and other legislation that can improve the lives of patients.⁶ This includes supporting the efforts of state medical societies lobbying for the redesign of prior authorization criteria, and using management programs to make the process more transparent and effective. Gary Bryant, MD, FACP, Chair, ACR’s delegation to the AMA’s House of Delegates, is also requesting that ACR members renew their AMA membership or join the AMA, and that they specify the ACR as their specialty organization to help leverage rheumatology-related advocacy activities.⁶

“The AMA is the largest physician organization and convener of all physician voices. It leverages the voices of the rheumatology community, on behalf of the specialty and our patients. We wouldn’t be able to do that ourselves given our size. It gives us a seat at the table for making policy,” said Dr Bryant.⁶

References

1. American Medical Association. 2016 AMA prior authorization physician survey. 2016. www.ama-assn.org/system/files/media-browser/public/government/advocacy/2016-pa-survey-results.pdf. Accessed February 3, 2017.
2. American Medical Association. Health care coalition calls for prior authorization reform. January 25, 2017. www.ama-assn.org/health-care-coalition-calls-prior-authorization-reform. Accessed February 3, 2017.
3. American Medical Association. Prior authorization and utilization management reform principles. www.ama-assn.org/sites/default/files/media-browser/principles-with-signatory-page-for-slsc.pdf. Accessed February 6, 2017.
4. American Medical Association. Status implementation of resolutions and report recommendations: AMA House of Delegates annual meeting - June 8-15, 2016. October 27, 2016. https://assets.ama-assn.org/sub/meeting/documents/a16-status-report.pdf. Accessed February 6, 2017.
5. Cover My Meds. National adoption scorecard: electronic prior authorization (ePA). 2015. https://epascorecard.covermymeds.com/pdf/CoverMyMeds_NationalAdoptionScorecard_March2015.pdf. Accessed February 6, 2017.
6. Devone-Pacheco C. Why keep a seat at the AMA table? January 18, 2017. www.the-rheumatologist.org/article/keep-seat-ama-table/. Accessed February 6, 2017.