Patient Outcomes

Elizabeth Briand

Recently, AMA released the results of its 2023 prior authorization physician survey. It showed a continuing and significant concern among physicians regarding the prior authorization process, which they see as a time-consuming barrier to the efficient and effective delivery of care. The nationwide survey included 1,000 practicing physicians—400 primary care and 600 specialists—and painted a stark statistical portrait of physician experiences with prior authorization.

Among the top issues were those surrounding the delay of treatment, with 94% of respondents saying that the prior authorization process sometimes, often, or always resulted in delays. When asked how often issues related to the prior authorization process led to patients abandoning their recommended course of treatment, more than three-quarters said “often” or “sometimes.” Perhaps most significantly, 24% reported that prior authorization had led to a serious adverse event for a patient in their care.

A worsening concern

AMA said that an increasing number of physicians are describing the prior authorization process as “out of control.” They noted that a decade ago, physicians and insurers were working together to reform the process—in part, through increased automation—with the goal of making the process faster, more efficient, and more transparent.

Today, physicians report that phone calls continue to be the most common method for completing prior authorizations and only 23% of physicians say that their EHR system provides electronic prior authorizations for prescription medications.

In 2018, AMA released their “Consensus Statement on Improving the Prior Authorization Process,” in partnership with APhA, the American Hospital Association, the Blue Cross Blue Shield Association, and others. This roadmap was designed to offer solutions that would reduce administrative burdens and improve access to timely care.  

By most accounts, the process has continued to deteriorate. Transparency remains an issue with 63% of physicians noting that it is “difficult to determine” whether a prescription medication requires prior authorization and 59% reporting the same for a medical service. Nearly one-third of physicians said that prior authorization requirement information in their EHR or e-prescribing systems was “rarely or never” accurate.

AMA noted that although several national insurers announced plans to voluntarily reduce the number of services needing prior authorization in 2023, physicians continue to report substantial requirements from nearly every major health plan.

Affecting patients and physicians alike

Although patients are the ones most directly impacted by the tumult of the current prior authorization situation, the process is also contributing to serious physician burnout and stress. One of the most difficult aspects for physicians, AMA reported, is “the moral injury of having their clinical judgment questioned. There is the emotional impact of seeing a patient get worse because of these requirements.”

The survey noted that 95% of physicians feel the prior authorization process somewhat or significantly increases burnout. They feel frustrated, too, with the system’s appeal process, often simply choosing a different care plan because they do not believe the appeal will be successful. Nearly half also reported that they simply cannot wait for the process to run its course because their patients need immediate care.

The peer-to-peer review process with health plan representatives also contributes to the hesitation in pursuing appeals. Only 15% of surveyed physicians said that the health plan’s peer often or always had the appropriate qualifications to evaluate the decisions.

AMA encouraged federal and state legislation to reform the prior authorization process. This past January, the CMS released a new rule designed to reduce patient care delays and electronically streamline the prior authorization process for physicians participating in Medicare, Medicaid, and the Children’s Health Insurance Program.

State legislatures are also working toward reform with more than 90 bills across 30 states introduced so far in 2024.

AMA encouraged pharmacists to get involved in the reform process, sharing their experiences with the organization to help make the case for change. AMA believes that pharmacists too often get caught in the middle, when patients come in to collect prescriptions that have been denied without their knowledge. Physicians and pharmacists, AMA said, are both working toward the same goal: providing the best care for their patients.  ■