AMA says health insurance industry is failing on prior authorization reform


The American Medical Association says that despite promises from the insurance industry to reform and improve prior authorizationslittle effort has been made to do so.

This comes despite evidence that insurer-mandated permissions can be dangerous and burdensome to patient-centered care.

In January 2018, the AMA and other national organizations representing pharmacists, medical groups, hospitals and health insurers signed a consensus statement outlining a common commitment to five key reforms for the prior authorization process. Together, the five reforms promote safe, timely and affordable access to evidence-based care for patients; increased efficiency; and reduced administrative burdens.

But the results of the AMA’s survey of physicians in December 2021 show little progress has been made, and the AMA questions whether the health insurance industry can be relied upon to voluntarily accelerate reform. full of heaviness prior authorization procedure that delays and disrupts patient-centred care.

“Waiting for a health plan to authorize necessary medical treatment is too often a health hazard to patients,” AMA President Gerald E. Harmon, MD, said in a statement. “Authorization controls that do not prioritize patients’ access to optimal care in a timely manner can lead to serious adverse consequences for waiting patients, such as hospitalization, disability or death. Comprehensive reform is needed now to stem the heavy toll that continues to mount without effective action.

The AMA survey examined the experiences of more than 1,000 medical practitioners with each of the five prior authorization reforms in the consensus statement and shows that the goal of comprehensive reform is far from complete.

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

Adjust the volume of requests
The list of drugs and services that require prior authorization should be regularly reviewed by insurers to remove items that show “low variation in use or low prior authorization denial rates,” according to the consensus statement. Most physicians (84%) reported that the number of drugs requiring prior authorization had increased. An equal majority of physicians (84%) said the number of medical services requiring prior authorization had increased.

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

Support continuity of patient care
Insurers must “minimize disruption to necessary processing”, including “minimize repetitive prior authorization requirements”, as stated in the consensus statement. An overwhelming majority of physicians (88%) said prior authorization interferes with continuity of care.

Accelerate the use of automation
Efforts should be made to accelerate the adoption of existing national standards for electronic transactions for prior authorizations, according to the consensus statement. Only about one in four physicians (26%) said their electronic health record system offers electronic prior authorization for prescription drugs.

Because of these failures, the AMA and other physician organizations are calling on Congress to address the issue through the Improving Access to Timely Care for Seniors Act (HR 3173 / S3018), which would codify much of the consensus statement.

Originally posted on our sister brand, Medical economics.


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