Elizabeth Spencer, 71, of Lebanon, Tennessee, stated that in order to obtain continuous glucose monitoring supplies, she must obtain preapproval from her Medicare Advantage plan every ninety-two days. Spencer, who was diagnosed with Type 1 diabetes at the age of twelve, estimates that she spends an hour a week completing the prerequisites for prior authorization.
Whereas patients experience delays in care, physicians are also exhausted due to its tedious process and are worried about health outcomes as well. According to a survey by the American Medical Association (AMA) in 2023, 94% among 1,001 physicians agreed that PA reduces access to care.
In the same AMA poll, 86% of doctors stated that prior permission policies increased the utilization of medical resources, causing wasteful spending rather than cost savings. More precisely, roughly two-thirds of doctors stated that prior-authorization policies caused patients to be diverted to ineffective initial treatments (64%) or additional office visits (62%), and 46% of doctors stated that prior-authorization policies resulted in patients receiving urgent or emergency care.
The prior authorization requirements are said by the health insurance industry to be based on evidence-based medicine; however, clinical experiences cast doubt on the practical applicability of opaque, insurer-created requirements. Merely 15% of medical professionals stated that evidence-based prior authorization criteria were frequently or always used.
According to Dr. Dipak Nandi, MD, Board Certified Physician, Neuropsychiatrist, and a graduate of All India Institute of Medical Sciences, New Delhi, India, “It is disheartening that despite our best efforts, healthcare providers are often unable to deliver timely care to our patients due to the burdensome and inefficient prior authorization processes.”
It's not just surveys that highlight the evidence of physician burnout due to prior authorization. Healthcare professionals frequently discuss the issue, both in private conversations and on social media platforms, where they share heart-wrenching stories almost daily.
With just a few keystrokes, one can find numerous posts by physicians detailing their struggles with prior authorization. These include stories such as:
- A patient who died in the intensive care unit from a massive pulmonary embolism. Despite a history of deep vein thrombosis, the patient had not received anticoagulant medication for months due to prior authorization delays.
- A teenage patient with an anterior cruciate ligament injury and a lateral meniscus tear who could not walk or bear weight due to a locked knee. Despite the necessity for surgery, prior authorization was required before proceeding.
- An infant diagnosed with brain cancer whose treatment was delayed because the insurer required prior authorization for accessing vital therapy.
- A patient was denied appropriate medications by the insurance company, resulting in a longer hospital stay, increased exposure to steroids, and prolonged symptoms due to the delay in optimal treatment.
These stories reflect the real-world impact of prior authorization on patient care and physician burnout, underscoring the need for a more efficient and patient-centered approach.
Steps Towards A More Efficient Prior Authorization Process
This year, the Centers for Medicare & Medicaid Services (CMS) finalized the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F). This rule establishes requirements for Medicare Advantage (MA) organizations, Medicaid and the Children’s Health Insurance Program (CHIP) fee-for-service (FFS) programs, Medicaid managed care plans, CHIP managed care entities, and issuers of Qualified Health Plans (QHPs) on the Federally Facilitated Exchanges (FFEs) (collectively referred to as "impacted payers"). The goal is to enhance the electronic exchange of health information and streamline prior authorization processes for medical items and services. These policies are expected to improve access to care by simplifying prior authorization, thereby reducing the burden on patients, providers and payers, and generating an estimated $15 billion in savings over ten years.
CMS is dedicated to removing obstacles in the healthcare system, making it easier for doctors and nurses to provide essential care. By increasing efficiency and enabling secure, seamless flow of healthcare data among patients, providers, and payers, CMS aims to streamline prior authorization processes, supporting better health outcomes and a more positive healthcare experience for all.
Although prior authorization can help ensure that medical care is necessary and appropriate, it often becomes a barrier to necessary patient care. Providers frequently face complex and varied payer requirements or long waits for prior authorization decisions. This final rule sets requirements for certain payers to simplify the prior authorization process and complements the Medicare Advantage requirements finalized in the Contract Year (CY) 2024 MA and Part D final rule. These changes include continuity of care requirements and aim to reduce disruptions for beneficiaries. Starting primarily in 2026, impacted payers (excluding QHP issuers on the FFEs) will be required to issue prior authorization decisions within 72 hours for expedited (urgent) requests and within seven calendar days for standard (non-urgent) requests for medical items and services.
As Dr. Dipak Nandi, the eminent neuropsychiatrist, has said, “With this new approach in prior authorization, we can hope for a better future for both our colleagues and patients.”
