Although health plans aim to promote value-based care with prior authorization requirements, providers and patients may experience negative repercussions from the process.
Prior authorization negatively impacted patients and providers alike by leading to care delays for patients and creating administrative burden for physicians, according to a survey from the American Medical Association (AMA).
Health plans use prior authorization to lower costs and further value-based care initiatives. However, the process can end up creating more problems on the provider end, an AMA survey of about 1,000 physicians found.
Physicians reported that prior authorization creates heavy administrative burden.
The survey found that physicians complete an average of 41 prior authorizations each week and spend an average of two business days on the processes. Forty percent of physicians have staff who exclusively complete prior authorizations.
What’s more, 88 percent of survey respondents reported that prior authorization generates high or extremely high burden.
Data from the Medical Group Management Association (MGMA) has also found that prior authorization requirements were the top regulatory burden for providers in 2021.
In addition to negative impacts on providers, prior authorization can harm patients, AMA found.
The majority of physicians (93 percent) reported that prior authorization sometimes, often, or always delayed access to necessary care for patients as they waited for health plans to authorize the service. More than eight in ten physicians said that prior authorization issues sometimes, often, or always led to patients abandoning their treatment.
Over a third of physicians reported that the process has led to a severe adverse event for a patient, while 24 percent indicated prior authorization has led to a patient’s hospitalization.
This negative impact on patients can subsequently affect employers and the workforce, AMA said.
“Health insurance companies entice employers with claims that prior authorization requirements keep health care costs in check, but often these promises obscure the full consequences on an employer’s bottom line or employees’ well-being,” Gerald Harmon, MD, president of AMA, said in a press release.
“Benefit plans with excessive authorization controls create serious problems for employers when delayed, denied or abandoned care harms the health of employees and results in missed work days, lost productivity and other costs.”
When asked to consider their patients in the workforce, 51 percent of physicians said that the prior authorization process has interfered with a patient’s ability to perform job responsibilities.
Despite the intent to further value-based care, 91 percent of physicians responded that prior authorizations have a somewhat or significant negative impact on patient clinical outcomes.
Legislators have also voiced their concern for prior authorization and its effect on patients, particularly seniors.
“The data is clear that the prior authorization status quo delays care, worsens health outcomes, and is an additional barrier for seniors, families, and medical providers,” Congresswoman Suzan DelBene (WA-01) said in a statement.
“We need to bring this practice into the 21st century so that seniors can get the medical attention they deserve when they need it. That’s why it’s critical we pass commonsense legislation like the Improving Seniors’ Timely Access to Care Act, which is cosponsored by a bipartisan majority of the U.S. House of Representatives.”
AMA’s survey also revealed that three in ten physicians feel that the criteria health plans use for prior authorizations are rarely or never based on clinical evidence.
“The findings of the AMA survey illustrate a critical need to streamline prior authorization requirements to minimize delays or disruptions in care delivery,” the press release stated. “Health plans agreed to make a series of improvements to the prior authorization process several years ago, but despite harmful consequences of delayed or disrupted care, most health plans are not making meaningful progress on reforms.”
AMA offered a series of recommendations for employers regarding prior authorization and health plan selection that may ultimately help improve patient outcomes.
First, employers should ask potential plans about prior authorization requirements and how they might impact employees. Second, employers should gather feedback from employees about their experiences with prior authorization. Finally, employers, patients, and providers can visit FixPriorAuth.org to learn more about prior authorization and sign AMA’s reform petition.
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