Few physicians will argue that prior authorization is an administrative headache. Now, however, there are mounting data showing that prior authorization does more harm than good.
Few physicians will argue that prior authorization is an administrative headache. Now, however, there are mounting data showing that prior authorization does more harm than good. But experts say there have been few meaningful changes in processes required to obtain payer authorization to prescribe certain drugs, order tests, or perform treatments.
“As urologists we’re hit in all areas with prior authorization,” said William C. Reha, MD, MBA, a urologist in Woodbridge, VA who is the American Association of Clinical Urologists (AACU) State Advocacy Network chair and an AMA delegate to the Medical Society of Virginia.
The morning of his interview with Urology Times, Dr. Reha said members of his staff were “pulling their hair out” trying to get approval for an MRI in a man with an elevated PSA to rule out prostate cancer.
Christopher Bayne, MD, a pediatric urologist at the University of Florida, Gainesville, took to Twitter when insurer Sunshine Health denied coverage for his 13-year-old patient’s hypospadias repair.
Dr. Bayne said his own documentation may have resulted in the denial, when he wrote that the repair wasn’t medically necessary. But Dr. Bayne, who has spent time trying to convince Sunshine Health that having a normal-looking penis is necessary for the boy’s psychological well-being, said his words fell on deaf ears.
“I think it’s important to understand that teenagers are very cognizant of their genitalia and sexual maturation. Suddenly, this boy who is very shy and timid is told that his penis is abnormal. I think it’s going to have pretty dramatic consequences potentially,” Dr. Bayne said.
Dr. Bayne compares covering hypospadias repair to repairing cleft lip, which is often covered.
“I think if the insurance companies would just listen to what you’re saying and handle things on a case-by-case basis, they would see that we are reasonable and we are trying to provide the best for patients,” Dr. Bayne said.
Prior authorization’s toll
The American Medical Association recently reported on findings from a survey of 1,000 practicing physicians, including specialists, asking about their experiences with prior authorization. The online survey, sent out in December 2018, suggests prior authorization can be more than an administrative burden. It can harm patients.
More than nine in 10 doctors said prior authorization has a significant or somewhat negative impact on clinical outcomes. More than one-fourth (28%) said prior authorization has led to a serious adverse event such as a death, hospitalization, disability, or permanent bodily damage. Three-fourths of physicians said prior authorization can lead to treatment abandonment, and 91% indicated it results in care delays.
Nearly 90% of those surveyed report prior authorization burdens have increased significantly or somewhat in the last 5 years, and 86% claim the burden associated with prior authorization is high or extremely high in their practices. More than one in three physicians surveyed by the AMA have hired staff to work on prior authorizations.
The bleak picture in medicine overall is much the same in urology, according to Christopher M. Gonzalez, MD, MBA, chair of the AUA’s Public Policy Council. The AUA surveyed members in 2016 and found prior authorization has profound impacts on the specialty.
“We found out urology offices were spending on average 14 hours a week on prior authorization. And it can be anywhere from one to three full-time equivalents that doctors’ offices have to hire to deal with this,” said Dr. Gonzalez, who is professor and chair of urology at Loyola Medicine and Loyola University Chicago Stritch School of Medicine, Maywood, IL.
The AUA survey found urologists were most likely to encounter the need for prior authorizations when prescribing medications, including those for overactive bladder, erectile dysfunction, cancer, and low testosterone. Prior authorizations are also common when urologists order CT or MRI scans or perform outpatient and inpatient surgery.
“The average time it takes a urology practice to make these calls is 19 to 20 minutes,” Dr. Gonzalez said. “So, we asked our doctors if this is a problem: 75% said the burden is high or extremely high for the practice, and 90% of our doctors said access to care is being delayed and patient care is being harmed.”
The denial rate in urology is about 24%, according to Dr. Gonzalez.
“So, three-fourths of the time, payers approve these things, but you have to jump through hoops,” he said.
The worst offender for prior authorization among insurers, according to the AUA survey, is Blue Cross Blue Shield, followed by United Healthcare and Aetna.
A 2019 study looked at what it costs physician practices to interact with health insurance plans, including for prior authorization. The authors estimated the cost to practices of interactions with plans is at least $23 to $31 billion annually (Health Aff [Millwood] 2009; 28:w533-43).
On its website, America’s Health Insurance Plans states: “Insurance providers use prior authorization under the supervision of medical professionals, promoting safe, timely, evidence-based, affordable and efficient care. Prior authorization requires advance approval of coverage for a medical service. It’s applied to less than 15 percent of treatments.”
The association did not respond to a request for an interview.
Next: Hope at the state levelHope at the state level
States are working on bills that could help providers and patients with burdens created by prior authorization. And for those states that need it, the AACU is there to help with its State Advocacy Network, according to Dr. Reha.
The AACU has a network in place to work with states to push forward urologist-supported legislation. That includes contact phone numbers and emails, information, and data, as well as the people power to lobby at the state capital, Dr. Reha.
States are making progress, with a number of bills proposed (see, “Select state proposals at a glance"). The Commonwealth of Virginia, for example, has two bills that address prior authorization issues supported by both the AACU State Advocacy Network and the Medical Society of Virginia, according to Dr. Reha.
In the Virginia Senate, SB 1607 includes several tenets pertaining to prior authorization, including the provision that “if a carrier has previously authorized an invasive or surgical health care service as medically necessary and during the procedure the health care provider discovers clinical evidence prompting the provider to perform a less or more extensive or complicated procedure than was previously authorized, then the carrier shall pay the claim, provided that it is appropriately coded consistent with the procedure actually performed.”
Another bill in Virginia, HB 2126, addresses step therapy reform by including a faster, more efficient exemptions process for patients who need treatments or are already on effective treatment, according to Dr. Reha. Step therapy is a process where prescribers have to try less expensive therapies before they can justify prescribing more expensive or newer therapies.
An example of harm from step therapy in urology is in treatment of overactive bladder.
“If you know somebody is going to respond to one of the newer generation overactive bladder agents or maybe they’ve been on it in the past and you know it’s going to work, the patient shouldn’t have to first fail something like oxybutynin chloride,” Dr. Reha said. “We’re not saying that everyone should go to the newer agents, but if there are medical reasons, there should be an exemptions policy.”
Both Virginia bills passed both the Senate and House unanimously and were awaiting the governor’s signature at press time.
Next: What’s being done nationallyWhat’s being done nationally
On a national level, the AUA is holding an annual insurance roundtable with commercial insurance representatives, Medicare administrative contractors, and specialty societies to develop relationships and come up with solutions, according to Dr. Gonzalez. The AUA held the first such event last November. The next is scheduled for Nov. 8, 2019.
The AUA is working with the AMA and has signed off on the AMA’s prior authorization reform principles. The AMA letter, “Prior Authorization and Utilization Management Reform Principles,” recommends 21 measures for future prior authorization policy. That effort led to the “Consensus Statement on Improving the Prior Authorization Process,” which outlines five areas of agreement for future policy making, authored by the AMA, American Hospital Association, America’s Health Insurance Plans, American Pharmacists Association, the Blue Cross Blue Shield Association and the Medical Group Management Association.
The AMA has a toolkit to help doctors navigate through prior authorization issues; see bit.ly/AMAresources. And the AUA has developed a prior authorization checklist and a guide to help navigate payers’ forms, available at bit.ly/AUAtools. (Also see, “Tips for easing prior authorization’s toll.")
The AUA continues to survey urologists about prior authorization. Dr. Gonzalez said it’s always at the top of the agenda when the AUA goes to Washington to advocate for the specialty and its patients.
Lately, he said, the AUA has also focused on reforms aimed at step therapy.
“Step therapy is rearing its head within Medicare Advantage. We’ve asked CMS to remove step therapy from Medicare Advantage,” Dr. Gonzalez said.
Urologists and others are aware of the cost concerns affecting the global health care economy, Dr. Reha said.
“I do think in a small way that prior authorization does have benefit. Unfortunately, the way it’s managed today is it’s extremely cumbersome, and I don’t think the amount of work really offsets the benefits. I think prior authorization needs to follow established guidelines that are set up by specialty societies,” Dr. Reha said.
“The best way that I as a doctor who is trying to provide cost-effective, competent, medically necessary care is by knowing, reading, and following the AUA guidelines.”