Most doctors got little relief from prior approval as COVID cases soared

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CHICAGO – As new cases of COVID-19 peaked in the United States in late 2020, most doctors reported that health plans continued to require bureaucratic pre-approval policies that delay access to essential care and sometimes cause serious harm to patients new poll results issued today by the American Medical Association (AMA).

“When the COVID-19 pandemic began in early 2020, some commercial health insurers temporarily eased pre-authorization requirements to reduce administrative burdens and help patients gain quick access to the drugs, tests and treatments they need,” said AMA President Susan R. Bailey , MD In late 2020, when the US healthcare system was overwhelmed with a record number of new COVID-19 cases per week, the AMA found that most doctors faced stringent licensing hurdles that delayed patient access to needed care. “

According to the AMA survey in December 2020, almost 70% of 1,000 resident doctors surveyed said that the health insurance companies either returned to previous approval contracts or did not even loosen them in the first place. More than nine in ten doctors (94%) said treatment was delayed while they waited for insurance companies to approve the necessary treatment, and nearly four in five doctors (79%) said that patients were due to treatment cancel approval disputes with the health insurance companies.

“Delayed and interrupted treatment due to an archaic prior approval process can have life-threatening consequences for patients, especially during a public health emergency,” said Dr. Bailey. “This hard lesson from the current crisis must be a re-examination of the administrative expenses of the health insurance companies, often without justification.”

Almost a third (30%) of doctors said, according to the AMA survey, that the prior authorization requirement resulted in a serious adverse event in a patient they were caring for. Specifically, the prior approval requirements led to the following effects for patients:

  • Hospitalization of patients – reported by 21% of doctors
  • Life-threatening event or intervention to avoid permanent impairment or damage – reported by 18% of doctors
  • Disability or permanent physical injury, congenital abnormality, birth defect or death – reported by 9% of doctors

While health insurers say the pre-approval criteria reflect evidence-based medicine, doctors’ experience casts doubt on the credibility of this claim. Only 15% of doctors said that the pre-approval criteria were often or always based on evidence-based medicine.

Other critical concerns from doctors highlighted in the AMA survey include:

  • Nine in ten doctors (90%) said pre-approval programs had a negative impact on patients’ clinical outcomes.
  • A clear majority of doctors (85%) stated that the burdens associated with prior approval were high or extremely high.
  • Doctors’ offices receive an average of 40 advance approvals per doctor and week, which corresponds to two working days (16 hours) of doctor and staff time.
  • In order to do justice to the administrative effort, two out of five doctors (40%) employ staff who only perform tasks in connection with prior approval.

The results of the AMA survey highlight the urgent need to streamline or eliminate low value pre-approval requirements in order to minimize delays or disruptions in supply. The AMA has taken a leadership role in advocating pre-approval reforms and convening key industry stakeholders to develop a roadmap to improve the pre-approval process.

In January 2018, the AMA and other national organizations representing pharmacists, medical groups, hospitals and health insurers signed a Consensus Statement Outline a shared commitment to improve five key areas related to the prior authorization process. However, the health plans have made little progress in implementing improvements in each of the five areas outlined in the consensus statement over the past three years.

The AMA continues to work on everyone front to streamline prior approval. Through our research, collaboration, advocacy, and leadership, the AMA works to design the right size pre-authorization programs so clinicians can focus on patients rather than paperwork. Patients can share their personal experiences with prior approval. share FixPriorAuth.org.

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