"As the demand for reforms to prior authorization has grown, policymakers have begun to take steps to address the issue," writes Yehuda A. Sugarman of the AACU.
Based on a partnership with Urology Times, articles from the American Association of Clinical Urologists (AACU) provide updates on legislative processes and issues affecting urologists. We welcome your comments and suggestions. Contact the AACU government affairs office at 847-517-1050 or firstname.lastname@example.org for more information.
In their ongoing effort to stem the cost of medical treatment, health care insurers have increasingly instituted prior authorization (PA) that require providers to justify prescribed drugs and treatments. Although the protocols offer some benefits, such as stemming overutilization and preventing a small contingent of patients from being prescribed unnecessary or potentially addictive medications, they have become synonymous with the inefficiencies and lack of transparency in the US health care system.
The PA process causes unnecessary obstacles to care and delays in treatment that can lead to adverse clinical consequences. In a 2020 AMA survey,1 nearly 80% of providers reported that long prior authorization processes were linked to patients abandoning their treatments, and 91% indicated it results in care delays. More disturbingly, 30% of physicians said PA has led to a “serious adverse event such as a death, hospitalization, disability, or permanent bodily damage.”
The management of PA also exacts a heavy administrative burden on health care providers, medical groups, and pharmacists. The requirements often vary widely from 1 insurer to the next, and there is no universal process for submitting PA requests to insurers, meaning it must be done manually, which drains significant time and human resources.
Perhaps most frustratingly, the vast majority of prior authorization requests are ultimately approved—somewhere between 71% and 96% of the time, based on several surveys that have been conducted on the topic. This raises the serious concern that insurers are instituting time-consuming PA requirements simply to deter the prescription of drugs and treatments, at the expense of patients.
If prior authorization requests are generally approved anyway, then insurers ought to at least institute a faster, more standardized and streamlined process for conducting reviews and handling appeals of prescribed treatments.
Urologists are united in opposition to prior authorization
A 2016 survey by the American Urological Association (AUA) found that urology offices were spending on average 14 hours a week on prior authorization requests. The AUA identified overactive bladder, cancer, erectile dysfunction, and low testosterone as the urologic conditions most commonly requiring PA prior to prescriptions being authorized to treat them.
According to American Association of Clinical Urologists (AACU) President Elliott Lieberman, MD, some insurers require, and often deny, prior authorization for CT and MRI scans used to help determine the best course of action for treating prostate cancers. “Prior authorization denials for sophisticated radiology testing leads to extensions of patients’ symptoms and dangerous roadblocks to the treatment of benign and cancerous conditions.”
In the Urology Times®’ 2019 State of the Specialty Survey,2 an astonishing 97% of urologists said they were either concerned or very concerned about prior authorization requirements. When asked to quantify the time they spend on practice administration, such as answering audits and obtaining pre-authorizations, 61% estimated devoting 1-9 hours per week on these tasks and 25% estimated spending 10-19 hours per week.
“For our 2-physician urology office, we were forced to hire a full-time employee simply to handle prior authorization,” said Terrence Regan, MD, who practices in Florida and chairs the AACU’s’ Health Policy Committee. “Urologists know what treatment is right for their patients’ health, not insurance company algorithms.
Regulatory efforts to reform prior authorization
As the demand for reforms to prior authorization has grown, policymakers have begun to take steps to address the issue.
On January 15, 2021, the Centers for Medicare & Medicaid Services (CMS) finalized a rule that would streamline and expedite prior authorizations. Under the Final Rule, payers have up to 72 hours to rule on prior authorizations for urgent requests, and 7 calendar days for non-urgent requests. To promote transparency, payers are also required to provide a specific reason for all denials and must make public certain metrics that demonstrate how many procedures they are authorizing.
The rule requires public payers to build application programming interfaces (API) that would allow providers to know in advance what documentation is needed for each health insurance payer and enable providers to send PA requests and receive responses electronically. These, along with other changes to streamline the documentation process, should improve the electronic exchange of health care data among payers, providers and patients, and reduce repeat PA requests.
Although the CMS rule represents an important step toward reducing provider and patient burden, it did not include Medicare Advantage (MA) plans, which cover about a third of Medicare beneficiaries. That omission could potentially result in more variation in prior authorization processes and reduce incentives for providers to adopt the new standardized procedures. In response to feedback, CMS is considering further rulemaking to make MA plans also subject to the new requirements.
Regardless, the CMS rule will take a few years to fully implement and rulemaking under the Biden administration could potentially change or undo the regulatory reforms. That’s why Congress is considering, with the broad support of organized medicine, legislation that would codify restrictions on the use and abuse of prior authorization protocols.
Federal legislation to address prior authorization
On May 13, bipartisan legislators in the U.S. House introduced the Improving Seniors' Timely Access to Care Act (H.R. 3173), which would implement a variety of changes to prior authorization processes in order to speed up communication, reduce paper work, increase transparency, and enhance oversight by CMS.
The legislation represents the culmination of efforts by a broad spectrum of health care providers and health plans to come to a consensus on how to improve the PA process. Among the notable changes H.R. 3173 would bring about are a requirement that MA plans implement an electronic prior authorization process, minimizing PA for routinely approved services, requiring PA requests to be reviewed by qualified clinicians, and requiring MA plans to meet beneficiary protection standards, such as ensuring continuity of care when patients change plans.
Stakeholders, who number more than 160 patient and provider groups, are optimistic the bill will advance during the current session of Congress after a similar version last year gained incredible momentum with 280 bipartisan cosponsors, or about 65% of U.S. House members. This year’s bill has already attracted 106 cosponsors in the House in just a couple of weeks.
As a longtime champion of prior authorization reform, the AACU has endorsed H.R. 3173 and is actively engaging its membership on the issue through online advocacy and by connecting urologists directly with key members of Congress, via UROPAC meetings, to request their support.
1. American Medical Association. 2020 AMA prior authorization (PA) physician survey. Accessed June 2, 2021. https://www.ama-assn.org/system/files/2021-04/prior-authorization-survey.pdf
2. Kerr R. State of the Specialty survey: Top pain points are revenue drop, prior auth. Urology Times®. December 16, 2019. Accessed June 2, 2021. https://www.urologytimes.com/view/state-specialty-survey-top-pain-points-are-revenue-drop-prior-auth