ChesterCountyMedicineSpring2019 - 16


Insurers' Progress On Fixing Prior
Authorization Is Disappointingly Slow


year ago, health insurance trade organizations agreed on the
need for plans to reduce unnecessary burdens and promote
timely access to care by revising their prior authorization (PA)
processes to be more data-driven and transparent, but new physician
survey results show that insurers have not widely implemented these
changes and the process has instead become more burdensome and
time consuming than ever.

"Physicians follow required insurance protocols for prior authorization that involve recurring paperwork, multiple phone calls and
hours spent on hold," said AMA President Barbara L. McAneny,
MD. "At the same time, patients' lives can hang in the balance until
health plans decide if needed care will qualify for insurance coverage."
Physicians are reporting an increase in PA volume that includes
requirements for drugs and services that are neither new nor costly.
This includes long-available generic drugs and prescriptions for patients
on an established medication regimen to manage a chronic condition.
The AMA has worked across several fronts to reform PA, including submitting an op-ed, producing videos on how PA harms
patients and burdens physicians, advocating with state legislatures
and collaborating with health plans.

16 CHESTER COUNT Y Medicine | SPRING 2019

The AMA worked with payer trade organizations America's
Health Insurance Plans (AHIP) and Blue Cross Blue Shield Association (BCBSA) and national associations representing hospitals,
pharmacists and medical groups to develop a PA reform consensus
statement that was released in January 2018.
The statement identified five opportunities to right-size PA, and
it included agreements to take specific actions on each of them. But
little to no progress has been made and, in some areas, the situation
is getting worse, according to 1,000 practicing physicians surveyed
in December 2018.
Under the consensus statement, AHIP and BCBSA agreed to
encourage their member health plans to:
Selectively apply PA and exclude physicians who have high rates
of PA approval, prescribe according to evidence-based guidelines or
participate in risk-based payment contractual agreements. Yet only
eight percent of physicians surveyed reported contracting with health
plans that offer programs exempting them from PA.
Adjust the volume of PA requirements to reflect drugs and
services with low variation in utilization or low PA denial rates.
However, instead of experiencing a reduction in the number of drugs
requiring PA, 88 percent of physicians said the number has gone
up. Similarly, 86 percent of physicians reported that the number of
services requiring PA has gone up, too.


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