Prior authorization—a process that requires physicians to obtain approval from health insurers before prescribing medication, conducting tests, or moving forward with treatment—continues to cause unnecessary patient care delays and even care abandonment by patients, according to the Pennsylvania Medical Society (PAMED). Another related problem is step therapy—which requires patients to try, and fail, on one or more prescription drugs, tests, or treatment options at the discretion of their insurance company before gaining access to the appropriate drug, test, or treatment option that was recommended by their physician.
There has been little relief from this decades-old problem for physicians and their patients during the COVID-19 pandemic, according to PAMED.
According to a recent American Medical Association (AMA) survey, almost 70 percent of 1,000 practicing physicians surveyed in December 2020 reported that health insurers had either reverted to past prior authorization policies or never relaxed these policies in the first place during the pandemic.
The new survey data also found that:
- 94 percent reported patient care delays caused by prior authorization
- 79 percent reported patients abandoning treatment altogether due to prior authorization hassles
- 30 percent reported that prior authorization requirements led to a serious adverse event for a patient, more specifically:
- Hospitalization – 21 percent
- Life-threatening event or intervention to prevent permanent impairment or damage
– 18 percent
- Disability or permanent bodily damage, congenital anomaly, birth defect, or death – 9 percent
- 90 percent reported that prior authorization has a negative impact on patient clinical outcomes
- 85 percent reported the burdens associated with prior authorization to be high or extremely high
- Only 15 percent reported that prior authorization criteria were often or always based on evidence-based medicine
- Medical practices complete an average of 40 prior authorizations per physician, per week, which equates to two business days of physician and staff time. To keep up with this administrative burden, 40 percent of physicians reported that they had to hire a full-time staff person to work exclusively on prior authorization tasks.
The findings of the AMA survey illustrate a critical need to streamline the prior authorization process to minimize delays or disruptions to patient care and treatment.