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Toll from prior authorization exceeds alleged benefits, say physicians


The approval process health insurers impose on medical services or drugs is generating a toll that exceeds the purported benefits, according to a physician survey (PDF) released today by the American Medical Association (AMA) and shared in a letter to federal health officials. While health insurers claim prior authorization requirements are used for cost and quality control, a vast majority of physicians say authorization controls lead to unnecessary waste and avoidable patient harm.

“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., M.D. “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.”

According to the AMA survey, more than four in five physicians (86%) reported that prior authorization requirements led to higher overall utilization of health care resources, resulting in unnecessary waste rather than cost-savings. More specifically, about two-thirds of physicians reported resources were diverted to ineffective initial treatments (64%) or additional office visits (62%) due to prior authorization policies, while almost half of physicians (46%) reported prior authorization policies led to urgent or emergency care for patients.

The health insurance industry maintains prior authorization criteria reflect evidence-based medicine, but physician experiences call into question the clinical validity of insurer-created criteria that lack transparency. Only 15% of physicians reported that prior authorization criteria were often or always evidence-based.

Other critical concerns highlighted in the AMA survey include:

Patient Harm - One-third of physicians (33%) reported that prior authorization led to a serious adverse event for a patient in their care, including hospitalization, permanent impairment, or death.

Bad Outcomes - Nearly nine in 10 physicians (89%) reported that prior authorization had a negative impact on patient clinical outcomes.

Delayed Care - More than nine in 10 physicians (94%) reported that prior authorization delayed access to necessary care.

Disrupted Care - Four in five physicians (80%) said patients abandoned treatment due to authorization struggles with health insurers.

Lost Workforce Productivity - More than half of physicians (58%) who cared for patients in the workforce reported that prior authorizations had impeded a patient’s job performance.

In addition, a significant majority of physicians (88%) said burdens associated with prior authorization were high or extremely high. This costly administrative burden pulls resources from direct patient care as medical practices complete an average of 45 prior authorizations per physician, per week, which consume the equivalent of almost two business days (14 hours) of physician and staff time. To keep up with the administrative burden, nearly two in five physicians (35%) employed staff members to work exclusively on tasks associated with prior authorization.

The AMA survey results illustrate a critical need to streamline or eliminate low-value prior authorization requirements to minimize waste, delays, and disruptions in care delivery. The AMA has taken a leading role in advocating for prior authorization reforms and today submitted comments (PDF) to the Centers for Medicare & Medicaid Service (CMS) largely supporting the agency’s proposals to improve prior authorization. These proposals align with the AMA’s 2017 Prior Authorization and Utilization Management Reform Principles (PDF) and 2018 Consensus Statement on Improving the Prior Authorization Process (PDF) and will significantly improve prior authorization across a number of federal and state insurance programs.

“The AMA greatly appreciates Administrator Brooks-LaSure’s reform proposal and its focus on the role of payer decision-making and electronic information exchange in the prior authorization process,” said Dr. Resneck. "CMS has proposed two sets of rules on prior authorization, and as in comments (PDF) on the initial rule, the AMA continues to applaud the administrator for acknowledging patient and physician concerns in both sets of proposed rules. 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.

The AMA continues to work on every front to streamline prior authorization. Through our Recovery Plan for America’s Physicians the AMA is working to right-size prior authorization programs so that physicians can focus on patients rather than paperwork. Patients, physicians, and employers can learn more about reform efforts and share personal experiences with prior authorization at

About the American Medical Association

The American Medical Association is the physicians’ powerful ally in patient care. As the only medical association that convenes 190+ state and specialty medical societies and other critical stakeholders, the AMA represents physicians with a unified voice to all key players in health care.  The AMA leverages its strength by removing the obstacles that interfere with patient care, leading the charge to prevent chronic disease and confront public health crises and, driving the future of medicine to tackle the biggest challenges in health care.

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