The burden insurance company prior-authorization (PA) requirements put on medical practices is rising significantly and causing a negative impact on patient outcomes, physicians said in a recent AMA survey.
On average, practices complete an average of 29.1 PAs per physician per week, with physicians and their staff spending nearly two business days on this workload. Beyond just the sheer volume of PAs facing practices is the inefficient, manual PA process that often relies heavily on the use of fax machines and telephone calls.
This story is part of the AMA’s Advocating for Patients and Physicians topic hub. Explore other Medical Topics That Matter.
To reduce the burden PA places on patients and practices, the AMA has launched a multipronged advocacy campaign to urge for reforms and right-sizing of insurers’ PA programs. Along with promoting improved transparency, protections for continuity of care and reduction in the overall number of services and drugs requiring PA, the AMA also advocates greater PA process automation through implementation of electronic prior authorization (ePA) technology.
To help physicians leverage this technology in their practices, the AMA created three videos about pharmacy ePA. The videos explain the issues associated with PA, how ePA works, and what physicians need to do to implement ePA technology.
Staying in the practice workflow
Standard ePA is an automated process that is integrated into the physician’s electronic prescribing workflow and is part of the practice’s electronic health record (EHR) system. It does not involve re-entering data into a health plan’s proprietary online portal, downloading forms from an insurance company website—and “certainly not using a fax machine,” as noted in the second video.
The ePA process begins when physicians select a medication in their electronic prescribing system and their EHR signals that PA is required. The ePA request is submitted to the health plan, which responds in real time with an electronic question set that applies specifically to the medication and the patient’s pharmacy benefit.
The questions are dropped into the EHR work queue and completed at the convenience of the physician or practice staff. The completed questions are then reviewed on a summary screen and submitted to the health plan. Physicians often receive ePA decisions within one minute of submitting the completed question set.
With an ePA approval in place, physicians can then send a “clean” prescription to their patients’ pharmacies, confident they won’t face delays due to unmet PA requirements. This is an important advantage of the ePA process, as rejection of prescription claims at the pharmacy is a major factor in patients’ medication nonadherence. In the AMA survey, nearly 80 percent of physicians said patients sometimes, often or always abandoned their recommended course of treatment due to prior authorization.
Other benefits of ePA include offering a uniform process, eliminating the need to manage numerous payer portals and accelerating time to treatment, and reduced time to therapy. The AMA survey found that 92 percent of physicians reported that PA sometimes, often or always delayed care.
“Because of the rapidly changing requirements and the number of health-plan drug lists, it’s often difficult for physicians to know which insurers will require PA for a given medication in a particular patient, so the PA process often begins when a patient learns from the pharmacist that their medication requires further approval,” Jack Resneck Jr., MD, chair-elect of the AMA Board of Trustees, told AMA Wire®. “My patients sometimes face delays of several days to receive their medication, leaving their condition untreated while they wait, and end up making additional trips to the pharmacy.”
Establishing demand for ePA with EHR vendors and getting health plans and benefit managers to support ePA technology will lead to greater access options and broader implementation.
While some EHR systems may require a costly upgrade to support ePA, the AMA advocates that vendors provide it for free. Also, the AMA helps state medical societies push for reforms that include mandating that health plans accept ePA transmissions.
Encouraging adoption of ePA technology is just one component of AMA’s wide-ranging strategy to improve PA for physicians and patients. AMA advocacy resources include principles for PA reform and a model bill that both address the need for transparency on PA requirements, public reporting of insurers’ PA program statistics and timely processing of PA requests.
The bill also contains a provision requiring that ePA be implemented using accepted industry standards. The model bill declares that “facsimile, propriety payer portals, and electronic forms shall not be considered electronic transmission.”
“We used the AMA’s model bill as a template to draft Ohio-specific legislation,” said Tim Maglione, the Ohio Medical Association’s senior director of government relations. “We wanted to get out of the realm of faxes and phone calls and move into a web-based electronic system to process PA requests.”
Maglione recalled that the Cleveland Clinic told legislators that, each month, it had to send an average of 430 repeat faxes because the initial fax for the PA request was not acted on.
Examples such as these highlight the need for major changes in insurers’ PA programs. In January, the AMA, along with other national provider associations and health insurer trade organizations, released a consensus statement on improving PA. The AMA will use this document in its continued efforts to push for meaningful PA reforms, including accelerated adoption of ePA to improve inefficiency and speed time to patient treatment.