Dive Brief:
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The American Medical Association (AMA) released a set of reform principles identified by a workgroup it convened that address what it see as an overuse of prior authorization requirements by payers.
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The workgroup, consisting of specialty medical societies, provider associations and patient representatives, claims prior authorizations, which are used by health plans as a cost-control measure, lack transparency, are inefficient, and may negatively impact patients when the process causes treatment delays.
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The 21 Prior Authorization and Utilization Management Reform Principles are intended to improve patient access to care and reduce the administrative burden on healthcare providers.
Dive Insight:
Any physician inundated with prior authorization requests at the beginning of a new plan year knows that they are time-consuming and therefore expensive. The workgroup also pointed out that prior authorizations, step therapy and similar “utilization management” programs stand in the way of patient-centered care.
At a time when providers have focused efforts on improving patient adherence to plans of care, their treatments are potentially delayed or interrupted by such programs. Meanwhile, health plans and benefit managers argue that the programs are needed to make sure patients get the appropriate treatment and to keep costs down. Because these views inherently make for an adversarial relationship, the AMA and its coalition seem to be hoping that reasonable compromises will bridge the gap between providers and payers.
For example, the coalition does not take the stance that all utilization management programs are a bad idea; rather, they insist that decisions be made not on cost alone, but with clinically accurate information. They want more flexibility, details of required documentation and decision-making criteria and the ability to discuss appeals directly with another provider, not an administrator. A principle that would mean a huge reduction in the administrative burden for providers is that prior authorizations “should be valid for the duration of the prescribed/ordered course of treatment.” That change would mean that patients with a stable regimen could focus on managing their health without fear of having to change medications every year.
From a clinical perspective, the 21 principles are eminently reasonable. But this is a list of requests, and as such, it lacks teeth. It took action by a state attorney general for Cigna to end prior authorization just for coverage of medication-assisted treatment of opioid abuse. Under financial pressure to show profits in an uncertain marketplace, it would seem they have little motivation to compromise.