Prior authorization leads to serious adverse events for patients, AMA survey says

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The prior authorization process continues to have a "devastating" effect on patient outcomes, physician burnout and employee productivity, according to a new physician survey from the American Medical Association.

In addition to negatively impacting care delivery and frustrating physicians, PA is also leading to unnecessary spending in the form of additional office visits, unanticipated hospital stays and patients regularly paying out-of-pocket for care, results showed.

In the AMA's annual survey of 1,000 practicing physicians, 94% reported that PA resulted in delays to care, while 78% reported that it can sometimes lead to the abandonment of treatment altogether.

More than one in three physicians said PA criteria is rarely or never evidence-based. And nearly one in four said it has led to a serious adverse event for a patient in their care: Nineteen percent said it led to a patient's hospitalization, 13% said it led to a life-threatening event or resulted in permanent damage, while 7% said it was responsible for a patient's disability or death.

WHAT'S THE IMPACT?

The AMA determined through its survey results that PA leads to substantial administrative burdens for physicians, taking time away from direct patient care, costing practices money and significantly contributing to physician burnout. 

"PA undercuts the financial stability of physician practices that are already struggling to stay solvent in this time of dwindling Medicare payments," the AMA wrote.

A full 95% of physicians said PA somewhat or significantly increases burnout, and about 27% said prior authorizations are often or always denied. One in five said they always appeal an adverse PA decision, but many don't appeal, with 62% saying they don't believe the appeal will be successful, and 48% saying the patient can't wait for the health plan to approve the PA.

According to the AMA, prior authorizations add significant cost to the healthcare system for a number of reasons. For example, patients are often forced to try ineffective treatments or schedule additional office visits because of PA requirements and delays. 

"These delays inevitably lead patients to seek more expensive forms of care, including emergency room visits, and can even lead to unexpected hospitalization," according to the AMA. 

Eighty-seven percent of physicians said PA leads to higher overall utilization. 

THE LARGER TREND

Earlier this week, physicians and medical student leaders at the AMA's House of Delegates approved policies aimed at fighting for greater insurer accountability and transparency regarding prior authorization requirements – issues which the AMA said are denying necessary care for patients and adding administrative burdens for physicians.

According to the AMA, health plans continue to inappropriately impose bureaucratic prior authorization policies that conflict with evidence-based clinical practices. These policies, in the group's view, jeopardize quality care, prompting the agency to advocate for increased legal accountability of health insurers when it's deemed that prior authorization is harming patients.

Surveys of physicians have generally found that excessive authorization controls required by health insurers lead to harm when necessary medical care is delayed, denied or disrupted. Investigations by the inspector general's office of the Health and Human Services Department and Kaiser Family Foundation into prior authorization by Medicare Advantage plans suggest that insurers are denying medically necessary healthcare.

A final rule issued by the Centers for Medicare and Medicaid Services in January deemed that impacted payers will be required to send prior authorization decisions within 72 hours for urgent requests and seven calendar days for standard requests.
 

Jeff Lagasse is editor of Healthcare Finance News.
Email: jlagasse@himss.org
Healthcare Finance News is a HIMSS Media publication.