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January/February 2019
Practice Matters: The Burden of Prior Authorizations In theory, requiring prior authorizations for certain diagnostic imaging or therapeutic treatments is a useful means of controlling health care costs and stemming the use of expensive testing and treatments in situations in which they aren't needed. But while the principle behind them might be valid, many physicians say prior authorizations result in a significant disadvantage for both physicians and patients. A March 2018 survey by the American Medical Association (AMA) reveals the extent of the problem from the physician point of view: 84% of physician respondents said they believe the burden associated with prior authorizations for providers and their staff is "high or extremely high." And a full 92% reported that prior authorizations have a negative impact on patient clinical outcomes. The survey results reflect the feedback he gets every day, says Jack Resneck, MD, a professor in the department of dermatology at the University of California, San Francisco and chair-elect of the AMA board. "At the AMA, we put a big focus on physician burnout and practice burdens that contribute to that, and in addition to problems with clunky EHRs and digital health technologies, prior authorizations are one of the top things that we consistently hear about," he says. The Burden for Physicians It's excessively time-consuming, he says, noting that insurance companies require more and more paperwork. "I understand that most of our rheumatological medications are expensive and costs should be considered, but the burden is immense and not reasonable," says Domingues, who is also the medical advisor to CreakyJoints, a nonprofit patient advocacy organization for individuals with arthritis that spends significant time advocating on the issue of prior authorization. According to the AMA survey, 86% of physicians say that the burden associated with prior authorizations has increased in the last five years, mainly due to the fact that the percentage of prescription drugs requiring prior authorizations has increased. "We've now gotten to a situation where everything—so many medications—need prior authorizations," says Robert Pearlstein, DO, a geriatric specialist practicing in Norristown, Pennsylvania, "Where it used to be just the expensive ones, the fancy medications, now it's almost every medication. Even if they're going to save two cents, they feel it's necessary to have a prior authorization." Although an increasing number of medications require prior authorizations, physicians are still often unaware of exactly when an authorization will be necessary. Often the health plans have the information available in some form, but it's difficult and time consuming to locate. "There's a transparency issue," Resneck says. "When the patient then shows up at the pharmacy and finds out—often from the pharmacist—that their prescription requires a prior authorization, it's often the first time the physician hears about it." Delays in Patient Care In the AMA survey, the majority of physician respondents (64%) reported waiting at least one business day for a requested authorization, and 30% reported waiting three business days or more. In the experience of Yul Ejnes, MD, a clinical associate professor of medicine at Brown University, it's rare that these delays are critical, although it happens occasionally. He points, as an example, to the situation of patients who develop symptoms of a urinary tract infection. "The antibiotic chosen happens to be one that requires a prior authorization because the preferred medications aren't appropriate due to allergies or previous problems with the drugs, and it happens to be Friday," Ejnes says. As a result, patients may not get their medications in a timely manner. "That's not an emergency situation, but it's an urgent situation," he says, noting that there is a risk of the infection spreading. Pearlstein agrees that prior authorization delays don't typically mean that patients go without needed medications. In the short term until the authorization comes through, he says, most patients will pay for the drugs themselves. In this case, the harm to the patient is primarily financial. But some physicians say the delays associated with prior authorization often are critical—especially in situations in which authorizations are denied and the physician has to appeal. "Unfortunately, I have bad stories to share, especially with vasculitis patients awaiting authorization for rituximab," Domingues says. "In some cases, prior authorizations delayed my patients from being able to access effective [rheumatoid arthritis] drugs for up to three months." Although drug companies usually supply samples for the intervening period, those samples are "a stop gap and not a solution," Domingues says. Often, the issue is not that insurance companies refuse an authorization outright, but that they require patients to fail a course of the insurance company's preferred medication before granting the authorization for the medication the physician wants to prescribe. In these instances, Domingues says, the delay can be roughly six months, which may lead to permanent joint damage in the patient population he sees. An especially frustrating aspect of the current system is that patients often have to get authorizations for the same medication more than once. Specifically, if a patient has already failed a "preferred" medication but then switches to a new insurer, the new insurer often requires the patient to fail the preferred medication all over again. A similar situation occurs whenever the formulary for a given drug changes. "You have to go through a lot of steps for something you have already proven to be appropriate," Ejnes says. Needed Reforms But while Pearlstein and others understand the payer rationale for prior authorizations, they also say the implementation needs improvement. Ejnes believes payers should avoid burdening all physicians equally and should focus on those who have a history of excessive ordering. "If a physician has a track record with the payer that every request they make is appropriate and approved, you'd think at some point the insurer would give them a pass and say, 'You're not the person we're looking for,'" he says. "The payers have data on different ordering patterns and they can identify outliers and focus their efforts on those physicians … and leave the rest of us alone, because right now it's basically penalizing everyone for what a few are doing." Payers should also keep historical data on previous prior authorization processes and exchange it among themselves rather than asking physicians to submit repeatedly if a patient changes insurers, he adds. While the majority of physicians in the AMA survey reported waiting less than three business days for prior authorization approval, a large minority (30%) reported waiting longer; thus, Domingues advocates for stricter limits on turnaround times, which he says should be no longer than 72 hours. And specialists, he says, should have the option of peer-to-peer appeal rather than having to make their case to nonspecialists. According to Resneck, the AMA is working with the insurer industry to promote reforms. In the last year, AMA representatives have met with leaders from several different health plans, including BlueCross/BlueShield and Anthem. The meetings have led to the development of a consensus statement, signed by multiple insurers, outlining a number of reforms that all signers—representing both physicians and insurers—agree would be beneficial.1 Among the reforms advocated in the consensus document are the following: • Reduction of treatments necessitating a prior authorization. It's not ideal, even on the insurer side, to require authorizations for medications or treatments that usually are approved, Resneck says. So a first point of agreement is that insurers should remove prior authorization requirements from diagnostic tests or medications that usually are approved. • Transparency. Instead of physicians being left to guess whether a prescription requires a prior authorization, they should receive a notification in their electronic health record (EHR) at the point of writing a prescription that states as much. • Automation. Not only should physicians be able to see in the EHR whether a particular treatment requires prior authorization, they also should be able to submit the authorization within the EHR, Resneck says. Physicians can already submit for a prior authorization electronically via insurer websites, but doing so requires transferring information from one system to another. This extra labor could be eliminated with better EHR integration. • Continuity of care. Patients who have been on a treatment plan and then switch health plans should be given at least some window of time in which to secure an authorization for continuity medications they had under their prior insurers, Resneck says. The same window of time should apply whenever insurers add a new prior authorization requirement where one didn't exist previously, he says. Although much work remains, there are definite signs of a changing environment with respect to prior authorizations, Resneck says. "I don't think the progress is necessarily going to be even across every health plan in the beginning," he says, adding that some health plans will most likely be leaders and innovators in the field, while legislation may be required in other cases to win relief for both physicians and patients. But whether it comes by cooperation or legislation, change is imperative, Resneck says. "The burden has gotten to a point where it is having a tremendous impact on physician practices and physicians' ability to care for patients and patients' ability to get access to treatment," he says. — Jamie Santa Cruz is a freelance writer based in Englewood, Colorado.
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