Dive Brief:

• With debates ongoing around prior authorization in the U.S. healthcare industry, a December 2021 survey by the American Medical Association found that 51% of physicians said the practice interfered with a patient's ability to perform his or her job responsibilities.
• The results included responses from 1,004 practicing U.S. physicians to questions about prior authorization, a process by which doctors must receive approval from a patient's insurer before they can administer a medication or treatment. Most respondents said prior authorization delayed necessary care and led patients to abandon a recommended treatment course at least somewhat often.
• Slightly more than one-third of physicians said prior authorization had led to a "serious adverse event" for a patient in their care. Most described the practice as highly burdensome, AMA said, with physicians and staff saying that they spent an average of nearly two business days per week completing prior authorizations.

Dive Insight:

The AMA is the largest physician lobby in the U.S. It has generally opposed prior authorization; its website refers to the process as "overused, costly, inefficient, opaque and responsible for patient care delays."

That puts the association at odds with insurers, which have cited prior authorization as a key cost-cutting measure in the healthcare space. Employers may feel similarly. A 2019 survey of employers by the International Foundation of Employee Benefit Plans, a nonprofit membership organization for benefits professionals, found prior authorization was one of the top five cost-cutting techniques cited by respondents.

Federal regulators at the Centers for Medicare and Medicaid Services have recently taken aim at changing prior authorization requirements. In January, CMS finalized a rulemaking requiring payers with plans in Medicaid, the Children's Health Insurance Program and on federal exchanges, to use standardized application programming interfaces for accessing prior authorization data, as well as requiring insurers to issue faster prior authorization decisions, Healthcare Dive reported.

Elsewhere, prior authorization has come up in the context of mental health and substance use care. In a report published earlier this month, the U.S. Department of Labor said it would focus its enforcement efforts on, among other items, analyzing prior authorization for in-network and out-of-network inpatient services. That is part of a broader effort to ensure health plans' parity between benefits related to mental health and substance use and other benefits.