Medical Groups Propose 21 Principles for Prior Authorization Reform

February 2, 2017

The American Medical Association and 16 patient, physician, hospital and pharmacy groups have issued a resounding message to health plans: it’s time to reform prior authorizations.  In a new principles document, the group calls for data-driven policies that don’t disrupt patient care or unduly burden physicians and their staff.

The group’s efforts build upon recent American Medical Association research, which quantified the negative impact of prior authorization.

The 21 Principles

“Prior Authorization and Utilization Management Reform Principles” focuses on:

  • Clinical validity. Utilization management techniques should be rooted in data, not just the desire to lower costs.
  • Continuity of care. Health plans should address step therapy with an emphasis on allowing stable patients to continue their course of care.
  • Transparency and fairness. Information on prior authorizations, formularies and cost sharing should be clear, publicly available, accurate, thorough and electronically searchable.
  • Timely access and administrative efficiency. Processes should entail timely communication and standardized criteria.  Authorization should guarantee subsequent coverage and payment.
  • Alternatives and exemptions. Under certain circumstances, physicians should be exempt or have an alternative to prior authorization.

Prior Authorization Findings

In a public statement on the principles, American Medical Association President Andrew W. Gurman, MD, noted that “oversight programs for drug or medical treatments have delayed access to necessary care, wasted limited health care resources and antagonized patients and physicians alike.”

The statement echoed findings from the association’s recent survey of 1,000 physicians.  Of those surveyed:

  • 23% said their staff completed more than 40 prior authorizations per week
  • 90% reported the prior authorization process delayed necessary care for patients
  • 75% said the requests were a “high” or “extremely high” burden on their practices.

Impact on Patient Access

Some patient groups have seen prior authorization become a significant barrier to access in recent years.  The utilization management technique remains a central battle for patients who need cures for hepatitis C, for example.  Some state Medicaid offices have imposed prior authorization processes with more than a dozen requirements.

Prior authorization also presents challenges for patients with cardiovascular conditions that require PCSK9 inhibitors.  And experiences with new cystic fibrosis treatments offer a harbinger of prior authorization challenges to come for patients with rare diseases.

The 21 principles are music to the ears of many physicians and their patients.  But will health plans, pharmacy benefit managers and utilization-review entities listen?

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