“We have partnered to identify opportunities to improve the prior-authorization process, with the goals of promoting safe, timely, and affordable access to evidence-based care for patients; enhancing efficiency; and reducing administrative burdens,” the organizations said in the statement. The associations also stress the importance of communication and collaboration between stakeholders in improving the prior authorization process.
The statement identifies five opportunities for improving the PA process and details agreements to take specific actions on each of these in order to achieve meaningful reform.
Selective application of prior authorization, which would include differentiating application of PA based on provider performance, adherence to evidence-based medicine or contractual agreements, such as participation in risk-based payment contracts.
PA program review and volume adjustment, which would include regular review of services, drugs and therapies that no longer warrant PA due to low variation of utilization or low PA denial rates.
Improved transparency and communication regarding PA to ensure timely resolution of PA requests to minimize delays in treatment and clearly articulate requirements, criteria, rationale and program changes.
Protections for continuity of patient care for individuals undergoing an active course of treatment when there is a formulary, treatment coverage or health plan change.
Automation to improve transparency and efficiency of PA requirements and processes, which includes moving toward industrywide adoption of electronic prior authorization transactions based on national standards and provision of formulary information and coverage restrictions at the point-of-care in electronic health records.
The December 2016 AMA survey of 1,000 practicing physicians found that physicians typically completed an average of 37 PA requests a week that took 16.4 hours to process.
If health plans reduce the number and scope of PA requirements, it’s hoped that patients will experience fewer delays or interruptions in receiving recommended treatment, according to Dr. Resneck.
“While the potential time savings will vary by practice and the health plans with which they contract, we are hopeful that the combined impact of fewer physicians being subjected to prior authorization, a reduction in the services and medications requiring prior authorization, and an increase in the use of electronic prior authorization will lead to time savings for physician practices,” Dr. Resneck said.
It’s about time—with patients
In addition to being optimistic about the gains that could be realized by reforming PA policies, he said it’s about time that technology solutions—such as the pharmacy electronic prior authorization workflow demonstrated in the AMA’s new three-part educational video series—be developed to streamline the PA process. (Other AMA PA resources include instruction on reducing administrative burden through electronic PA, model legislation and a PA toolkit.)
“One of my biggest frustrations is that health plans, pharmaceutical manufacturers, pharmacy benefit managers, and electronic health record [EHR] vendors haven’t yet worked together to give physicians real-time information in our EHRs at the point-of-care about which drugs are on-formulary, how much they actually cost, and whether they require prior authorization or step therapy,” Dr. Resneck said.
“The consensus statement shows that there is growing agreement across the entire health system that prior authorization programs and processes need to be ‘right-sized,’” Dr. Resneck said. “And it reflects a willingness among physicians, pharmacists, medical groups, hospitals and health plans to try to work together to achieve changes that both ensure that patients have access to timely and necessary care and medications, while reducing administrative burdens to physician practices and other health care professionals.”