Prior authorization (PA) — a health plan administrative process that requires providers to obtain approval before performing a service to qualify for payment—continues to be a major source of frustration among physicians due to the patient-care delays and practice burdens caused by this process. Last year, the American Medical Association (AMA) launched a multifac-eted campaign about this issue and captured the attention of both the media and health plans on the need for PA reform. PA remains a high-priority concern in 2018, and the AMA is engaged in a variety of research, advocacy, and educational efforts to address the physician and patient impact of health plans' PA requirements.
Building an Evidence Base
Any successful advocacy campaign requires a solid evidence base, and the AMA is building the case for PA reform with quantitative data detailing the patient and physician practice harms associated with health plans’ PA programs. In December 2017, the AMA conducted a survey of 1,000 practicing physicians. The survey results establish the significant effect PA burdens can have on timely patient care. Among surveyed physicians, 64% reported waiting at least one day for PA decisions from health plans, while 30% reported waiting at least three business days (see Figure 1). Not surprisingly, 92% of physicians said that PA can delay access to necessary care (see Figure 2).
These delays may have serious implications for patients, as 78% of physicians reported that PA can lead to treatment aban-donment (see Figure 3), and 92% indicated that PA can have a negative impact on patient clinical outcomes (see Figure 4).
The survey results also capture the significant impact of PA on physicians. On average, practices reported completing 29.1 total PAs (both prescription and medical services) per physician per week, with this PA workload requiring 14.6 hours—approximately two business days—of physician and staff time. An overwhelming majority (84%) of physicians characterized PA-related burdens as high or extremely high (See Figure 5). Moreover, PA hassles have been growing over time, with 86% of physicians reporting that PA burdens have increased over the past five years (See Figure 6).
These data illustrate PA’s significant—and rising—effect on patients and physician practices, as well as reinforce the need for strong advocacy efforts on PA reform. An important landmark in the AMA’s work on this issue was the January 2017 release of a set of 21 Prior Authorization and Utilization Management Reform Principles. The AMA, along with a coalition representing state and specialty medical societies, hospitals, medical groups, pharmacists, and patients, developed the principles, and over 100 additional provider and patient groups have signed on to the principles as formal supporters. The principles detail common-sense changes needed to improve PA programs and address areas of clinical validity, transparency and fairness, timeliness and administrative efficiency, continuity of care, and alternatives and exemptions.
The principles have spurred conversations with health plans about the need for significant improvement in health plans’ utilization management requirements. One result of these discussions was the January 2018 release of the Consensus Statement on Improving the Prior Authorization Process by the AMA, American Hospital Association, America’s Health Insurance Plans, American Pharmacists Association, Blue Cross Blue Shield Association, and Medical Group Management Association (www.ama-assn.org/sites/default/files/media-browser/public/arc-public/prior-authorization-consensus-statement.pdf
). This document reflects agreement between provider and health plan organizations to pursue PA reform in several key areas, including reduction in the overall volume of PAs, improved transparency and communication, protection of continuity of care, and automation to increase process efficiency.
While the principles and consensus statement focus on voluntary reform by health plans, state legislative efforts also play a critical role in the AMA’s campaign to improve PA processes. The AMA is working with state and specialty medical societies to enact legislation to protect both physicians and patients from PA burdens. The AMA offers model legislation on PA—the “Ensuring Transparency in Prior Authorization Act” (www.ama-assn.org/sites/default/files/media-browser/specialty group/arc/model-bill-ensuring-transparency-in-prior-authorization.pdf
)—that addresses a variety of important aspects of this issue, including improved transparency of PA requirements, public reporting of health plans’ PA program data, duration of PA approvals, timeliness of PA decisions, and support for standard electronic PA transactions. The AMA’s model bill serves as the basis for many state bills, and the AMA’s Advocacy Resource Center provides resources and support for these state-based reform efforts. This year alone, more than 20 states are addressing utilization management reform in their legislatures.
Raise Your Voice: Grassroots Efforts
Individual stories can help personalize an issue and enhance advocacy efforts. That’s why the AMA has built grassroots activities into its PA reform campaign. PA-related content has been added to both the Patients Action Network and Physicians Grassroots Network websites. Both sites illustrate the barriers PA can place between physicians and patients and include a “share your story” call to action, which is echoed in an accompanying social media campaign. The AMA will use the stories collected via these grassroots web tools to put a human face on the PA problem and further strengthen advocacy efforts.
The AMA also offers educational resources to help physicians and their staff reduce the manual burdens associated with PA and transition to automated processes. A new, three-part educational video series describes the current impact of the PA workload on physician practices, demonstrates the workflow improvements and other advantages of implementing pharmacy electronic PA transactions that integrate with electronic health record systems, and offers tips on how practices can start using this technology. This activity has been approved for AMA PRA Category 1 Credit™ and is worth 0.25 credit hours. The AMA also offers a Prior Authorization Toolkit, which summarizes the current PA landscape, offers tips for minimizing manual PA burdens, and discusses future changes needed to streamline the PA process.
A variety of changes are needed to improve health plans’ PA programs, and the AMA is devoting significant resources to addressing all of these important concerns—from reducing the overall volume of PAs to improving PA-related transparency, efficiency, and continuity of patient care. The AMA’s work to protect patients and physicians from PA burdens and effect meaningful change is continually evolving. To learn the latest about these advocacy efforts, and to access all of the resources mentioned in this article, visit www.ama-assn.org/prior-auth