Put “Patients Before Paperwork” by advancing policies that will eliminate unnecessary red tape and improve prior authorization processes for patients and their physicians.
Why Action is Needed
Unnecessary administrative requirements can prevent timely and appropriate treatment by forcing physicians to divert time and focus away from their patients. Two of the most common types of administrative burden in health care are prior authorization and step therapy.
Prior authorization is a common practice by health insurers to require physicians to first secure approval before a patient can receive their medications, tests, or procedures. It involves paperwork and phone calls, as well as varying data elements and submission mechanisms that force physicians to enter unnecessary data in electronic health records (EHRs) or perform duplicative tasks outside of caring for their patients. This prevents clinical decision-making at the point of care and is an unnecessary burden for physicians and barrier to medical care for patients. Step therapy is another practice implemented by health insurers, which can disrupt patient care and hinder access to treatment. It requires patients to try and fail at lower-priced drugs selected by their insurer before the drug prescribed by their physician is covered.
While addressing the rise of health care is very important, there is growing concern that these types of cost-utilization protocols do more harm than good. Not only can they cause financial burden to physicians, but they also contribute significantly to the current physician burnout epidemic. Medicare Advantage (MA) plans can require enrollees to receive prior authorization before a service will be covered, and nearly all MA enrollees (99 percent) are in plans that require prior authorization for some services in 2023. Further, in 2022, a survey of more than 500 doctors from group practices found that 89 percent believe that regulatory burdens increased in the past year, and 82 percent responded that the prior authorization process is very or extremely burdensome. Additionally, the Department of Health and Human Services issued a report in 2022 that detailed abuse in the prior authorization process in which “MA insurers sometimes delayed or denied beneficiaries’ access to services, even though the requests met Medicare coverage rules.”
Despite these findings, MA plans continue to utilize prior authorizations at alarming rates. Further, a 2024 congressional investigative report determined a growing number of MA plans are utilizing artificial intelligence (AI) tools to help make prior authorization determinations. While AI has the potential to improve prior authorizations processes, there must be parameters in place to prevent discriminatory practices that would inappropriately delay or deny medically necessary care for patients.
In addition to prior authorizations and step therapy, physicians are increasingly faced with an overload of alerts and messages in their virtual inboxes, causing them to divert their time away from doing what they do best, treating their patients.
ACP’s Position and Advocacy
ACP’s Patients Before Paperwork initiative serves as the foundation for policy recommendations for revising, streamlining, or removing entirely burdensome administrative tasks. The framework and recommendations call attention to the need to better understand the daily issues physicians face, including obstacles to prior authorization, in order to improve patient care.
ACP also supports prior authorization reform with private payers. In 2023, ACP successfully collaborated with other medical specialty societies to address egregious prior authorization requirements. Due to our advocacy efforts, United HealthCare changed its burdensome protocol for its gastrointestinal (GI) endoscopy prior authorization program and Cigna removed approximately 25 percent of medical services from prior authorization requirements.
At the federal level, ACP continues to advocate for legislative and regulatory policy changes to improve prior authorization and step therapy processes for patients and clinicians. We call on Congress to act now and do its part to improve physicians’ ability to provide seamless evidence-based care for their patients without unnecessary administrative delays.
Call to Action
- Reintroduce and pass the Improving Seniors’ Timely Access to Care Act, which would require that MA plans establish an electronic prior authorization process for real-time decision.
- Prevent discriminatory practices using artificial intelligence in prior authorization determinations.
- Support the reintroduction and passage of the Safe Step Act to ensure patient access to appropriate treatments based on clinical decision-making and medical necessity rather than arbitrary step therapy protocols.