The burdens associated with prior authorization are many, taking valuable time and resources away from patient care and significantly contributing to physician and staff burnout.  A recent American Medical Association (AMA) 2019 survey of physicians found that 86% of respondents described the burden associated with prior authorization as high, with respondents reporting on average completing 33 prior authorizations per physician per week, and physicians and their staff spending an average of almost two full business days per week completing prior authorizations.  In addition, a recent article published by the AMA discusses how prior authorizations have contributed to significant practice costs – upwards of $10 million dollars every year incurred by the Cleveland Clinic alone.

“physicians and their staff spending an average of almost two full business days per week completing prior authorizations”

Prior authorization also reduces patient access to care as payers routinely limit access to treatment options, including interventional pain and surgical procedures that our members furnish. The same AMA survey found that prior authorization significantly delayed patient access to necessary care (for 91% of respondents) and sometimes or often led to treatment abandonment (for 74% of respondents).  Clinical outcomes were also negatively impacted according to the vast majority of physicians surveyed (90%). To understand how this affects patients, consider this scenario that occurred in the context of a private payer’s prior authorization program.  Here, prior authorization delays for a spinal cord stimulator resulted in eight months of pain, depression, and anxiety for a patient with serious back pain, not to mention hours of physician time away from patient care.

In recognition of these substantial burdens, ASRA recently provided feedback to the Centers for Medicare & Medicaid Services (CMS) regarding "CMS-9123-P - Medicaid Program; Patient Protection and Affordable Care Act; Reducing Provider and Patient Burden by Improving Prior Authorization Processes, and Promoting Patients' Electronic Access to Health Information for Medicaid Managed Care Plans, State Medicaid Agencies, CHIP Agencies and CHIP Managed Care Entities, and Issuers of Qualified Health Plans on the Federally-Facilitated Exchanges; Health Information Technology Standards and Implementation Specifications."

ASRA recommends that CMS:

• Finalize proposals to require payers to implement the document requirement lookup service (DRLS) and prior authorization support (PAS) application programming interfaces (APIs).
• Expand proposals for DRLS and PAS APIs to apply to prescription drugs and covered outpatient drugs.
• Minimize the use of prior authorization under the fee-for-service (FFS) Medicare program.
• Support requirements for payers to implement “gold-carding” programs that remove or reduce prior authorization burden for providers with a history of compliance.

ASRA also reiterated its desire to work with CMS on this and other related issues to support physicians and patients affected by pain.

Read  the full letter.