The AMA says the health insurance industry is failing in a previous certification reform

The American Medical Association says that despite promises by the insurance industry to reform and improve previous permits, little has been done.

This comes despite evidence that permits imposed by the insurer can be dangerous and burdensome for patient care.

In January 2018, the AMA and other national organizations representing pharmacists, medical groups, hospitals and health insurers signed a consensus statement outlining a shared commitment to five key reforms to the prior authorization process. Taken together, the five reforms promote safe, timely and accessible access to evidence-based patient care; increased efficiency; and reducing administrative burdens.

But the findings of the AMA Doctors’ Survey in December 2021 show little progress, and the AMA is questioning whether the health insurance industry can be relied on to voluntarily accelerate a comprehensive reform of the cumbersome prior authorization process. which slows down and disrupts patient-centered care.

“Waiting for a health plan to allow the necessary medical treatment is too often a danger to patients’ health,” AMA President Gerald E. Harmon, MD, said in a statement. “Authorization controls that do not prioritize patients’ access to timely, optimal care can lead to serious adverse consequences for waiting patients, such as hospitalization, disability or death. A comprehensive reform is now needed to halt the severe damage, which continues to increase without effective action. “

The AMA study examines the experiences of more than 1,000 practitioners with each of the five preliminary resolution reforms in the Consensus Declaration and illustrates that the goal of the overall reform is far from complete.

Selectively apply the requirements
Prior authorization requirements should be applied selectively to physicians based on demonstrated adherence to evidence-based guidelines and quality measures, according to the consensus declaration. The results of the survey show that less than one in ten doctors (9%) have contracted with health plans that offer programs that selectively apply pre-authorization requirements.

Adjust the volume of requirements
The list of medicines and services that require prior authorization should be regularly reviewed by insurers to remove items that show “low variation in use or low levels of refusal of prior authorization”, according to the consensus statement. Most doctors (84%) reported that the number of drugs requiring prior authorization had increased. An equal majority of doctors (84%) report that the number of medical services that need prior authorization has increased.

Make the rules clear and accessible
Insurers must “promote transparency and easy access to prior authorization requirements, criteria, justification and changes to the program,” the consensus statement said. Almost two thirds of doctors (65%) report that it is difficult to determine whether a drug requires prior authorization. Slightly fewer doctors (62%) report that it is difficult to determine whether a medical service requires prior authorization.

Support patient continuity of care
Insurers must “minimize interruptions in the necessary treatment”, including “minimizing recurring prior authorization requirements”, as stated in the consensus declaration. The vast majority of doctors (88%) report that prior authorization interferes with continuity of care.

Accelerate the use of automation
Efforts should be made to speed up the adoption of existing national standards for electronic prior authorization transactions, according to the consensus statement. Only about one in four (26%) doctors report that their electronic health record system offers electronic prior authorization for prescription drugs.

As a result of these failures, the AMA and other medical organizations are urging Congress to address the issue through the Elderly Access to Timely Care Act (HR 3173 / S 3018), which will codify much of the consensus statement.

This article originally appeared in Medical EconomicsĀ®.

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