AMA finds most physicians had little relief from prior authorization as COVID cases soared

April 7, 2021

As new cases of COVID-19 in the United States were peaking in late 2020, most physicians reported that health plans continued to impose bureaucratic prior authorization policies that delay access to necessary care and sometimes result in serious harm to patients, according to new survey results issued today by the American Medical Association (AMA), reported the association.

“As the COVID-19 pandemic began in early 2020, some commercial health insurers temporarily relaxed prior authorization requirements to reduce administrative burdens and support rapid patient access to needed drugs, tests and treatments,” said AMA President Susan R. Bailey, M.D. “By the end of 2020, as the U.S. health system was strained with record numbers of new COVID-19 cases per week, the AMA found that most physicians were facing strict authorization hurdles that delayed patients’ access to needed care.”

According to the AMA survey, almost 70% of 1,000 practicing physicians surveyed in December 2020 reported that health insurers had either reverted to past prior authorizations policies or never relaxed these policies in the first place. More than nine in 10 physicians (94%) reported care delays while waiting for health insurers to authorize necessary care, and nearly four in five physicians (79%) said patients abandon treatment due to authorization struggles with health insurers.

“Delayed and disrupted treatment due to an archaic prior authorization process can have life-or-death consequences for patients, especially during a public health emergency,” said Dr. Bailey. “This hard- learned lesson from the current crisis must guide a reexamination of administrative burdens imposed by health insurers, often without any justification.”

Nearly one-third (30%) of physicians reported that prior authorization requirements have led to a serious adverse event for a patient in their care, according to the AMA survey. More specifically, prior authorization requirements led to the following repercussions for patients:

·        Patient hospitalization—reported by 21% of physicians

·         Life-threatening event or intervention to prevent permanent impairment or damage—reported by 18% of physicians

·         Disability or permanent bodily damage, congenital anomaly, birth defect, or death—reported by 9% of physicians 

While the health insurance industry says prior authorization criteria reflect evidence-based medicine, the physician experience casts doubt on the credibility of this claim. Only 15% of physicians reported that prior authorization criteria were often or always based on evidence-based medicine.

Other critical physician concerns highlighted in the AMA survey include:

·         Nine in 10 physicians (90%) reported that prior authorizations programs have a negative impact on patient clinical outcomes.

·         A significant majority of physicians (85%) said the burdens associated with prior authorization were high or extremely high.

·         Medical practices complete an average of 40 prior authorizations per physician, per week, which consume the equivalent of two business days (16 hours) of physician and staff time.

·         To keep up with the administrative burden, two out of five physicians (40%) employ staff members who work exclusively on tasks associated with prior authorization. 

In January 2018, the AMA and other national organizations representing pharmacists, medical groups, hospitals and health plans signed a consensus statement outlining a shared commitment to improving five key areas associated with the prior authorization process, including:

1. Selective Application of Prior Authorization.

2. Prior Authorization Program Review and Volume Adjustment.

3. Transparency and Communication Regarding Prior Authorization.

4. Continuity of Patient Care.

5. Automation to Improve Transparency and Efficiency.

However, health plans have made little progress in the last three years toward implementing improvements in each of the five areas outlined in the consensus statement, states AMA.

According to a June 12, 2020 press release from the U.S. House of Representatives, a bipartisan majority of the U.S. House of Representatives now supports the Improving Seniors’ Timely Access to Care Act of 2019 (H.R. 3107), introduced by Representatives Suzan DelBene (WA-01), Mike Kelly (PA-16), Roger Marshall, M.D. (KS-01), and Ami Bera, M.D. (CA-07). The bill would streamline and standardize prior authorization in Medicare Advantage (MA) and make the use of prior authorization more transparent. 219 members of Congress are now co-sponsors of the legislation.

“Clinicians and medical staff should be spending their time with patients, not faxing back and forth with insurance companies over procedures that are routinely approved. We are pleased to see a bipartisan majority of the House now agrees. The changes included in the Improving Seniors’ Timely Access to Care Act of 2019 will provide much-needed relief for providers and this bill is evidence that there is still a place for bipartisanship in Washington,” said Reps. DelBene, Kelly, Marshall, and Bera, stated the release.

Recognizing the importance of this issue, this legislation has gained support by over 400 organizations across the country, continued the release.

“The Arthritis Foundation strongly supports H.R. 3107 because this bipartisan legislation would make necessary patient-centered reforms,” said Ann Palmer, President and CEO, Arthritis Foundation. “Our surveys consistently tell us that prior authorization is a top concern for people with arthritis and their families. We are pleased to see the bill reach this impressive milestone in the legislative process and look forward to its passage into law,” added release.

“Neurosurgeons take care of very sick patients who suffer from painful and life-threatening neurologic conditions such as brain tumors, debilitating, degenerative spine disorders and stroke, and without timely medical care, our patients often face permanent neurologic damage, and sometimes death. Streamlining prior authorization will help ensure that our seniors get the care they need without delay, and we are thrilled that a bipartisan majority of the House of Representatives now supports H.R. 3107,” said Ann R. Stroink, M.D., on behalf of the American Association of Neurological Surgeons and Congress of Neurological Surgeons,” continued the release.

Additionally, in a June 11, 2020 press release, the Regulatory Relief Coalition urged Congress to enact the Improving Seniors’ Timely Access to Care Act legislation.

“When their vision is at risk, our patients can’t wait for their treatments,” said ophthalmologist George A. Williams, MD, immediate past president of the American Academy of Ophthalmology. “We are thrilled that the Improving Seniors’ Timely Access to Care Act has received such strong bipartisan support. We applaud Representatives Suzan DelBene, Mike Kelly, Roger Marshall, and Ami Bera for taking bold steps that will protect America’s seniors from unnecessary barriers that deny them of timely access to medically necessary care,” stated the release.

“It is especially critical coming out of the COVID-19 crisis, that patients not face additional obstacles to getting the care they need,” said Ann R. Stroink, MD, a practicing neurosurgeon from Bloomington, Ill. “My patients have faced delays in their surgery for several months, so relieving prior authorization burdens will help,” Dr. Stroink added, continued the release.

The release added that the Improving Seniors’ Timely Access to Care Act of 2019 would:

• Establish an electronic prior authorization process;

• Minimize the use of prior authorization for routinely approved services;

• Ensure prior authorization requests are reviewed by qualified medical personnel;

• Require regular reports from Medicare Advantage plans on their use of prior

authorization and rates of delay and denial; and

• Prohibit the use of prior authorization for medically necessary services performed

during pre-approved surgeries or other invasive procedures.

AMA stated that patients can share their own personal experiences with prior authorization at

AMA has the release.

More COVID-19 coverage HERE.