Doctors know all too well the countless hours and frustrations spent dealing with insurance companies' prior authorization practices, and the AMA and other medical organizations have been fighting to fix the system.
Patients and doctors saw a significant victory in january The Centers for Medicare and Medicaid Services (CMS) announced a final rule that will save physician practices about $15 billion over a decade by reducing delays in patient care and electronically streamlining the prior authorization process for physicians. But there is still work to be done at the state and federal level.
Patient advocacy groups (groups traditionally focused on disease-specific research and awareness, advocacy, and patient connection and empowerment) have increasingly joined the effort to effect meaningful reforms for patients and the doctors. These organizations are also collecting data and anecdotes to advocate for patients who have been sharing complaints about how prior authorization is harming their access to care.
“Patients are not always seen as equal participants in this, but they are. CMS and others often seemed surprised that patients wanted to be informed and involved. There is not enough understanding of how much time patients spend managing their care,” Anna Hyde, vice president of advocacy and access at the Arthritis Foundation, said in an interview with the AMA.
She and a leader from the Leukemia & Lymphoma Society spoke at the 2024 AMA State Advocacy Summit to detail why they are engaging in this advocacy fight and sharing patient stories and prior authorization data.
At all levels, patient voices are critical to turning the tide on payers' prior authorization practice, which wastes time and delays care. Finally, nine states passed some form of preclearance reform legislation in 2023, and nearly 30 states have preclearance bills before their legislatures so far this year.
Establishing prior authorization is a critical component of the AMA Recovery Plan for American Doctors.
Prior authorization is overused and existing processes present significant administrative and clinical concerns. Discover what the AMA is like address prior authorization with resources for research, practice and reform.
Data and stories emerge
After hearing anecdotal stories about patients' experiences with prior authorization, patient advocacy organizations set out to find more data and details to better quantify what was happening.
In developing a white paper on patients' prior authorization experience, the Leukemia and Lymphoma Society called on its patient community to tell stories. Lucy Culp, the organization's executive director of state government affairs, shared the story of a Minnesota woman who experienced numerous denials during the diagnosis period only to later be told by her insurance company that they would need to review and approve each of her 12 prescribed chemotherapy treatments. visits instead of approving all treatment for the woman, named Kelly.
“You can imagine the stress and anxiety Kelly felt at the thought of being told no every time and having to stop treatment or face thousands of dollars in medical bills,” Culp said.
Prior authorization has repeatedly emerged as an issue for arthritis patients over the years. To delve deeper into patient experiences, the Arthritis Foundation surveyed more than 3,000 patients and held two focus group sessions in 2023. Among its findings:
- 43% of patients went through prior authorization the first time a medication was prescribed.
- 37% of patients go through prior authorization each plan year.
- Three days was the average wait time for prior authorization approval, but 31% of respondents said they had waited more than a week.
- Approvals were granted 88% of the time.
- 43% appealed the denials and were unsuccessful; 28% appealed and were successful; 28% did not bother to appeal.
- 55% used different medications or no medication when the appeal was unsuccessful.
One patient with arthritis described prior authorization as a “hurricane,” Hyde said. The patient stockpiled medications to avoid interruptions in treatment in anticipation of another long and cumbersome prior authorization process.
These data are very consistent with the AMA's own. doctors survey (PDF), which found that 80% of doctors said prior authorization at least sometimes led patients to abandon treatment. It is also supported by the 2023 research results presented by another panelist, Kate Pestaina, director of the Patient and Consumer Protection Program at KFF, formerly known as the Kaiser Family Foundation.
Visit FixPriorAuth.org to see how patients, doctors and healthcare professionals across the country are negatively affected by prior authorization burdens and to Share your story.
