AMA survey: Prior authorization causes many patients to abandon care, raises healthcare costs
Prior authorization is frustrating to clinicians and a leading cause of burnout, and a new survey from the American Medical Association (AMA) shows it also frustrates patients to the point of abandoning care. The the AMA’s annual nationwide prior authorization survey of 1,000 practicing physicians also sheds light on other PA impacts, including actually raising healthcare costs due to additional patient visits and emergency hospitalization of patients because they could not be treated sooner.
Prior authorizations (PAs) have been a growing way health insurance plans try to control costs by requiring healthcare professionals to obtain advance approval from the health plan before a prescription medication or a medical service qualifies for payment and can be delivered to the patient. The AMA says while health plans and benefit managers contend PA programs are necessary to control costs, physicians say these programs are time-consuming barriers to the delivery of necessary treatment. The survey also indicates PA can harm patients by making them wait for diagnostic tests and therapy.
“As this year’s findings demonstrate, the PA process continues to have a devastating effect on patient outcomes, physician burnout and employee productivity. In addition to negatively impacting care delivery and frustrating physicians, PA is also leading to unnecessary spending, such as additional office visits, unanticipated hospital stays and patients regularly paying out-of-pocket for care,” the AMA said in a statement.
More than nine in 10 surveyed this year said that prior authorization has a negative impact on patient clinical outcomes. The AMA said the most telling result is that 78% of physicians reported that prior authorization often or sometimes results in their patients abandoning a recommended course of treatment.
The survey results showed 22% of respondents said patients pursue treatment abandonment often, and 56% said sometimes.
One of the key advocacy areas for the AMA is in reducing prior authorization burdens. Read more about recent efforts - AMA wants insurers to be accountable when prior authorization harms patients.
Delays in care due to prior authorizations
The survey found 94% of physicians say PA causes delays in the delivery of care. About 55% of respondents said care is delayed “always” or “often.”
The AMA said PA delays have led to 24% of doctors saying it led to a serious adverse event for their patients. Of these, 19% of respondents reported a delay led to the patient being hospitalized, 13% said it led to a life-threatening event that required intervention to prevent permanent impairment or damage, and 7% said a PA led to a patient’s disability, birth defects or death.
Physicians also reported feeling that for patients requiring a PA, it impacted their health in 93% of cases. Only 6% said PAs had no impact.
“Across the country, physicians see firsthand the dangerous, harmful—and sometimes deadly—consequences of prior authorization,” AMA President Bruce A. Scott, MD, wrote in a Leadership Viewpoints column accompanying the survey’s release. He accused insurance providers of deliberately causing physicians and patients hardships in order to save the company money by making it difficult and time consuming to access care.
“Payers erect roadblocks and hurdles allegedly designed to save money for the health system and protect precious resources, but when patients and their doctors face care delays—or even give up and abandon necessary care—the results can increase overall costs when worsening health conditions force patients to seek urgent or emergency treatment. Our patients are caught in the middle, twisting in the wind, while physicians fight for them, often with fax machines as our only available weapon,” Scott said.
Impact of prior authorization on physician practices
Physicians have long reported PA leads to substantial administrative burdens for physicians, taking time away from direct patient care, and costing practices money because of in creased staff time involved in making PA requests and appealing denials. Physician organizations and the AMA also said PAs are significantly contributing to physician burnout. In this survey, 95% of physicians said they felt PA contributes to feeling of burnout.
“PA undercuts the financial stability of physician practices that are already struggling to stay solvent in this time of dwindling Medicare payments,” the AMA said.
The most recent survey shows on average practices need to complete 43 prior authorization requests per physician, per week. Physicians and their staffs spend about 12 hours each week completing PAs, rather than on patient care. About 35% of survey respondents also said they have staff who work exclusively of PA.
The frustration of PAs and the time involved has also led to only 1 in 5 of physicians saying they appeal PA denials. This is because 62% say they do not feel the appeal will be successful based on past experience.
Other factors for not appealing include 48% of respondents saying a patient’s care could no longer wait for a PA approval. About 48% of doctors said they so not have enough staff or time to appeal PAs that are denied.
Insurance companies want doctors to speak to often unqualified peers
When navigating the PA process, especially when appealing a denied health plan PA decision, the AMA survey showed physicians are often required to participate in a “peer-to-peer (P2P) review” with a health plan representative. Almost two out of three physicians (61%) report at least sometimes having to participate in P2P reviews. P2P reviews require the physician to speak directly with a health insurance plan representative, which the AMA said disrupts patient appointments and consumes significant physician time.
As the frequency of P2Ps is increasing, and physicians often do not speak to an appropriately qualified “peer,” the survey found. Only about 15% of physicians participating in P2Ps report that the health plan’s “peer” often or always has the appropriate qualifications to make a decision about a patient’s care.
About 56% of respondents also said the number of P2P reviews have in leased over the past 5 years. Only 8% felt these meetings have decreased.
Increasing healthcare costs due to prior authorizations
The AMA said PAs add significant costs to the entire healthcare system because patients are often forced to try ineffective treatments and/or schedule additional office visits because of PA requirements and delays. The association also said these delays often lead patients to seek more expensive forms of care, including emergency room visits, and sometimes lead to unexpected hospitalizations.
PAs often work on a tiered system, where a patient is required to go in for less expensive tests that are often ineffective and then will be granted the authorization for more expensive tests or therapy. Despite this causing additional healthcare expenditure, 69% of respondents report ineffective initial treatments. About 68% reported the tiered system requiring additional office visits.
About 42% reported patients ended up going to immediate care and emergency rooms because their initial therapy or testing did not work, and 29% reported patient hospitalizations due to the way the system works.
Patient frustration with the PA system also leads to 79% of respondents saying it sometimes leads patients to pay out of pocket for a medication rather than jumping through additional hoops and wasting additional time, especially if they need to take time off of work or travel long distances. About 53% of physicians with patients in the workforce report that PA has impacted their patients’ job performance.
Health insurance company prior authorization performance
Prior authorization has created enough issues with administrative burdens and preventing access to safe, timely care, the AMA, along with the American Hospital Association, American Pharmacists Association, Medical Group Management Association, America’s Health Insurance Plans, and Blue Cross Blue Shield Association, created the Consensus Statement on Improving the Prior Authorization Process (CS) in January 2018. This was designed to help alleviate PA administrative burdens and stream line the PA system. The AMA said several national insurers announced plans to voluntarily reduce the number of services that require PA in 2023, but physicians report consistently high PA burdens across major health plans.
“Unfortunately, physicians report that health plans have made little progress honoring their commitments as outlined in the CS,” the AMA said.
Failure too meet the guidelines were found in these areas:
• Only 8% of physicians saying health pans use selective application of PA, such as offer programs that exempt providers from PA in gold card programs.
• A strong majority of physicians report that the number of PAs required for prescription medications (83%) and medical services (82%) have increased over the last five years.
• 55% of physicians report that PA is at least sometimes required for a generic medication.
• A majority of physicians report that it is difficult to determine whether a prescription medication (63%) or medical service (59%) requires PA.
• 29% physicians report that the PA requirement information provided in their electronic health record (EHR) or e-prescribing system is rarely or never accurate, leading to poor transparency.and communications.
• 88% of physicians report that PA interferes with the continuity of care.
• 59% physicians report that PA at least sometimes destabilizes a patient whose condition was previously stabilized on a specific treatment plan.
• Physicians reported using the phone as the most commonly used method for completing PAs, rather than the recommended use of automation to improve transparency and efficiency.
• Only 23% of physicians report that their EHR system offers electronic PA for prescription medications.
UnitedHealthcare and Humana had the highest PA requirements, according to 62% and 60% respondents respectively. Cigna, Aetna and Anthem/Elevance scored about 55% as having high to extremely high PA requirements. Blue Cross Blue Shield (BCBS)scored the lowest among the top payors with 52% saying they had high to extremely high PA requirements.
Between all the major health plans, BCBS scored the best among respondents, with 14% saying they had low PA requirements. All other plans scored below 10% for having low PA requirements among respondents.
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: dfornell@innovatehealthcare.com