A Third of Docs Blame Prior Authorizations for Serious Harm to Patients

One in three physicians blamed prior authorization for a patient’s serious adverse event, including hospitalization, permanent impairment, or death, according to a survey published by the American Medical Association (AMA) on Monday.

In addition, 86% of physicians surveyed said prior authorization rules led to greater use of healthcare resources overall.

“Health plans continue to inappropriately impose bureaucratic prior authorization policies that conflict with evidence-based clinical practices, waste vital resources, jeopardize quality care, and harm patients,” said AMA President Jack Resneck Jr., MD, in a press release. “The byzantine system of authorization controls is rife with opportunities for reform and the AMA continues to work with federal and state officials on legislative solutions to reduce waste, improve efficiency, and protect patients from obstacles to medically necessary care.”

Prior authorization requirements were enacted by insurers to stop physicians from ordering expensive and unnecessary tests or procedures in the name of cost-effectiveness. However, physicians have argued that such policies prevent access to routine care or critically needed treatments and increase overall use of healthcare resources.

Physician practices complete an average of 45 prior authorization requests per week, translating to about 14 hours, or roughly 2 business days. Approximately 35% of physicians said they have staff whose sole job is managing prior authorization requests.

The survey also highlighted the following impacts of prior authorization requirements:

• 64% of physicians said as a result of requirements, resources were steered towards “ineffective initial treatments”
• 62% said requirements led to additional office visits
• 46% said requirements led to urgent or emergency care

Beyond waste and inefficiencies, 94% of physicians said prior authorizations delayed patient access to necessary care “always,” “often,” or “sometimes.” By that same measure, 80% of physicians said prior authorization requirements led patients to “at least sometimes” abandon recommended treatment, and 89% said the requirements had a “somewhat” or “significant” negative impact on patients’ clinical outcomes.

More than half of physicians with patients in the workforce said that prior authorization rules have impacted their patients’ job performances.

Curiously, a majority of physicians surveyed — 58% — said that prior authorization criteria were rooted in evidence-based medicine or guidelines from national medical specialty societies; 31% said that such criteria were “rarely” or “never” evidence-based, and another 11% weren’t sure.

In December, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would require some payers to automate their prior authorization processes, mandate deadlines for certain prior authorization decisions — 72 hours for expedited requests and 7 calendar days for non-urgent requests — and require the provision of reasons for denials.

“The AMA continues to applaud the administrator for acknowledging patient and physician concerns in both sets of proposed rules,” Resneck noted. “The AMA also provided the administrator with several recommendations to strengthen CMS’ proposals, particularly around the rule’s scope, payer transparency, and processing time requirements.”