Last Updated: Apr 8, 2021
HARRISBURG (April 8, 2021) – Prior authorization – a process that requires physicians to obtain approval from health insurers before prescribing medication, conducting tests, or moving forward with treatment – continues to cause unnecessary patient care delays and even care abandonment by patients. Another related problem is step therapy – which requires patients to try, and fail, on one or more prescription drugs, tests, or treatment options at the discretion of their insurance company before gaining access to the appropriate drug, test, or treatment option that was recommended by their physician.
There has been little relief from this decades-old problem for physicians and their patients during the COVID-19 pandemic.
According to a recent American Medical Association (AMA) survey, almost 70 percent of 1,000 practicing physicians surveyed in December 2020 reported that health insurers had either reverted to past prior authorization policies or never relaxed these policies in the first place during the pandemic.
The new survey data also found that:
- 94 percent reported patient care delays caused by prior authorization
- 79 percent reported patients abandoning treatment altogether due to prior authorization hassles
- 30 percent reported that prior authorization requirements led to a serious adverse event for a patient, more specifically:
- Hospitalization – 21 percent
- Life-threatening event or intervention to prevent permanent impairment or damage – 18 percent
- Disability or permanent bodily damage, congenital anomaly, birth defect, or death – 9 percent
- 90 percent reported that prior authorization has a negative impact on patient clinical outcomes
- 85 percent reported the burdens associated with prior authorization to be high or extremely high
- Only 15 percent reported that prior authorization criteria were often or always based on evidence-based medicine
- Medical practices complete an average of 40 prior authorizations per physician, per week, which equates to two business days of physician and staff time. To keep up with this administrative burden, 40 percent of physicians reported that they had to hire a full-time staff person to work exclusively on prior authorization tasks
The findings of the AMA survey illustrate a critical need to streamline the prior authorization process to minimize delays or disruptions to patient care and treatment. Think this doesn’t affect us here in Pennsylvania? Think again! Read tragic patient stories here.
How can we fix prior authorization in Pennsylvania?
Sen. Kristin Phillips-Hill and Rep. Steven Mentzer recently introduced legislation – House Bill 225 and Senate Bill 225 respectively – that would reform the onerous prior authorization and step therapy (fail first) processes that are delaying appropriate patient care and increasingly undermining longstanding decisions made between physicians and their patients for the betterment of patient health care.
The Pennsylvania Medical Society (PAMED) has been and continues to be a strong supporter of prior authorization legislation, and is part of the nearly 40-member Coalition to Improve Prior Authorization and Step Therapy for Pennsylvanians.
While insurance plans claim to use these processes to control costs, patients and medical professionals often experience delays in care and much wasted time as a result.
“What this means for patients is simple…your physicians’ hands are tied in delivering excellent care by health insurance companies,” said PAMED President Michael DellaVecchia, MD, PhD, FACS, FICS, FCPP. “We have to go through prior authorization and denials, after which the insurers tell us, as an alternative, keep the patient on their regular medication when we know that treatment has failed our patients in the past,” said Dr. DellaVecchia. “Why jeopardize their health? That unfortunately is part of the process of prior authorization.”
If enacted, Senate Bill 225 and House Bill 225 would curb restrictive prior authorization and step therapy (fail first) practices imposed by health insurers, as well as bring transparency and consistency to the processes of the delivery of good health care.
About the Pennsylvania Medical Society
PAMED is a physician-led, member-driven organization representing all physicians and medical students throughout the state. We advocate for physicians and their patients, educate physicians through continuing medical education, and provide expert resources and guidance to help physicians and their organizations navigate challenges in today’s ever-evolving health care system. For more information, visit www.pamedsoc.org.