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).

“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 Dec. 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.

The findings of the AMA survey illustrate a critical need to streamline or eliminate low-value prior-authorization requirements to minimize delays or disruptions in care delivery. The AMA has taken a leading role in advocating for prior authorization reforms and convening key industry stakeholders to develop a roadmap for improving the prior authorization process.

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. 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.

The AMA continues to work on every front to streamline prior authorization. Through our research, collaborations, advocacy and leadership, the AMA is working to right-size prior authorization programs so that physicians can focus on patients rather than paperwork. Patients can share their own personal experiences with prior authorization at FixPriorAuth.org.