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 recently released by the American Medical Association (AMA) and shared in a letter to federal health officials.1 Although 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.
According to the AMA survey, 86% reported that prior authorization requirements led to higher overall use 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%) because of prior authorization policies, and almost half of physicians (46%) reported that prior authorization policies led to urgent or emergency care for patients.
Physician Concerns
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. Just 15% of physicians surveyed reported that prior authorization criteria were often or always evidence-based.
Other critical concerns highlighted in the AMA survey include the following:
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.
Poor Outcomes—A total of 89% reported that prior authorization had a negative impact on patient clinical outcomes.
Delayed Care—Most physicians surveyed (94%) reported that prior authorization delayed access to necessary care.
Disrupted Care—Four out of five physicians (80%) said patients abandoned treatment because of 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 surveyed physicians (88%) said burdens associated with prior authorization were high or extremely high. This costly administrative burden often 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 2 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.
REFERENCE
1. AMA: 2022 AMA prior authorization physician survey. Available at https://www.ama-assn.org/system/files/prior-authorization-survey.pdf. Accessed March 17, 2023.
