Healthcare Stakeholders Coalition Calls For Preauthorization Reforms

By Christine Kern, contributing writer

The proposal offers 21 principles for prior-authorization requirements.

The American Medical Association (AMA) and 16 additional healthcare organizations representing hospitals, medical groups, patients, pharmacists, and physicians have come together to respond to “unreasonable hurdles for patients seeking care” by urging widespread reforms of prior authorization requirements imposed on medical tests, procedures, devices, and drugs. The AMA also provided a list of 21 principles, divided into five broad categories, to guide the changes in prior-authorization requirements in a blog post.

“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,” AMA President Andrew W. Gurman, MD, said in a statement. “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.”

A December 2016 survey of physicians found physicians spend an average of 16 hours of practice time on their weekly per physician average of 37 prior-authorization requirements. The AMA and other stakeholders feel this is too much, creating an administrative burden that hampers the proper use of medical interventions and slows appropriate diagnosis and care of patients.

The AMA also found 75 percent of surveyed physicians described prior authorization burdens as high or extremely high, while more than a third of surveyed physicians reported having staff who work exclusively on prior authorization.

Nearly 60 percent of surveyed physicians reported their practices wait, on average, at least one business day for prior authorization decisions, and more than 25 percent of physicians said they wait three business days or longer, according to the AMA. Significantly, nearly 90 percent reported prior authorization use “sometimes, often, or always delays access to care.”

“Concerns that aggressive prior authorization programs place cost savings ahead of optimal care have led Delaware, Ohio and Virginia to recently join other states in passing strong patient protection legislation,” the AMA said.

Among the coalition members is The Medical Group Management Association, whose President and CEO, Halee Fischer-Wright, says, “Health plan demands for prior approval for physician-ordered medical tests, clinical procedures, medications, and medical devices ceaselessly question the judgement of physicians, resulting in less time to treat patients and needlessly driving up administrative costs for medical groups. Most importantly, despite the fact that the vast majority of prior authorization requests are ultimately approved, jumping through these administrative hoops can lead directly to delay or disruption in the delivery of care to the patient.”