AMA Says Health Insurance Industry Fails to Reform Prior Authentication

The American Medical Association says the insurance industry shows promise for reform and improvement despite this prior approvalslittle effort has been made to do so.

This is despite evidence that insurer-imposed approvals for patient-centric care can be dangerous and onerous.

In January 2018, the AMA and other national organizations representing pharmacists, medical associations, hospitals and health insurance companies signed a consensus statement It outlines a shared commitment to five key reforms to the prior authorization process. Taken together, the five reforms promote safe, timely and affordable access to evidence-based care for patients; improved efficiency; and less administration.

However, the results of the December 2021 AMA Physician Survey show little progress has been made, and the AMA questions whether the health insurance industry can be counted on to voluntarily accelerate sweeping sluggishness reform prior approval process delaying and disrupting patient-centred care.

“Waiting for a health plan to authorize necessary medical treatment is too often a hazard to patient health,” AMA President Gerald E. Harmon, MD, said in a statement. “Eligibility controls that do not prioritize patient access to timely, optimal care can result in serious adverse outcomes for waiting patients, such as: B. Hospitalization, disability or death. Comprehensive reform is now needed to stem the high toll, which will continue to mount without effective action.”

The AMA survey examined the experiences of more than 1,000 medical practitioners with each of the five pre-licensing reforms in the consensus statement and makes it clear that the goal of a comprehensive reform is far from being achieved.

Apply requirements selectively
According to the consensus statement, prior authorization requirements should be selectively applied to physicians based on demonstrated adherence to evidence-based guidelines and quality measures. Survey results show that fewer than one in ten physicians (9%) have contracts with health plans that offer programs that selectively apply prior approval requirements.

Adjust the volume of requests
The list of drugs and services that require prior authorization should be periodically reviewed by insurers to remove items that the consensus statement says have “low variability in use or low prior authorization rejection rates.” Most physicians (84%) indicated that the number of medicines requiring prior authorization has increased. An equal majority of physicians (84%) indicated that the number of medical services requiring prior authorization has increased.

Make rules clear and accessible
Insurers should “promote transparency and easy accessibility of pre-approval requirements, criteria, rationale and program changes,” the consensus statement reads. Almost two-thirds of physicians (65%) said it is difficult to determine whether a drug requires prior approval. Slightly fewer physicians (62%) indicated that it is difficult to determine whether a medical service requires prior authorization.

Support the continuity of patient care
Insurers should “minimize disruptions to needed treatment,” including “minimizing repeated prior approval requirements,” according to the consensus statement. An overwhelming majority of physicians (88%) indicated that prior authorization compromises continuity of care.

Accelerate the deployment of automation
According to the consensus statement, efforts should be made to accelerate the adoption of existing national electronic transaction standards for prior authorization. Only about one in four (26%) physicians reported that their electronic health record system offers electronic pre-approval for prescription drugs.

Because of these shortcomings, the AMA and other physician organizations are asking Congress to address the issue through the Improving Timely Access to Care for the Elderly Act (HR3173 / S3018) that would codify much of the consensus statement.

Originally released on our sister brand, medical economics.

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