Author + information
- Hadley Wilson, MD, FACC, Chair, ACC’s Board of Governors and
- Robert Shor, MD, FACC, Chair, ACC Membership Committee, Past Chair, ACC Board of Governors∗ ()
- ↵∗Address for correspondence:
Dr. Robert Shor, American College of Cardiology, 2400 N Street NW, Washington, DC 20037.
For years now, prior authorization has been impeding patient access and burdening cardiovascular practice management. However, cardiovascular professionals are no strangers to practice challenges, particularly after weathering an incredible amount of change in the last decade. From making sense of national health care reform, to physician employment and health system integration, and to the increase in use of technology and electronic health records, both physicians and care team members—and their patients—have been affected by constant change in health care. Prior authorization continues to be one such challenge that negatively affects patient care, increases administrative burden, and pushes clinicians away from direct patient contact.
Prior authorization—the approval from an insurer that may be required before patients receive a treatment or medication to be covered by that insurer—has plagued patients and practices for years. Over the past decade, prior authorization requirements have rapidly expanded from cardiac imaging testing and cardiac catheterizations/percutaneous coronary intervention to electrophysiology implantations. Most recently, prior authorizations for cardiovascular prescription medications are taking up more office time and resources due to the introduction of higher priced drugs (proprotein convertase subtilisin/kexin type 9s and nonvitamin K antagonist oral anticoagulants), fluctuating costs of some genetic drugs, and limited payer formularies. Collectively, these onerous requirements translate into patients experiencing delays in care, or outright denials by payers to cover needed tests, procedures, or medications.
Of course, these prior authorization problems are not limited to the practice of cardiology. The entire provider community is dealing with similar concerns and hassles. According to a 2016 survey by the American Medical Association (AMA), an overwhelming majority of surveyed physicians (90%) reported that prior authorization sometimes, often, or always delays access to care. In the same survey, nearly more than one-half of physicians (60%) reported that their practices wait an average of at least 1 business day for insurers to provide pre-approval for a test, procedure, or drug, and more than one-quarter (25%) said they wait at least 3 business days (1).
The survey also showed that more than one-half of physicians experience a 20% rejection rate from insurers on first-time prior authorization requests for drugs (1). According to a recent survey by the American College of Cardiology (ACC), the suspicion that patient care and safety are at risk due to prior authorization issues is being confirmed, as more than three-quarters of cardiology respondents (77%) noted that less time was spent on patient care due to the time required for medical documentation and the prior authorization process (2).
Practices are burdened by the prior authorization process on a daily basis. The AMA survey reports that three-quarters of physicians (75%) feel that the prior authorization burden on the staff in their practice is high or extremely high. This adds costs to physicians and practices who need to hire additional staff to process and follow prior authorization requests, and in many cases, the funding for such staff is nonexistent (1). In the ACC survey, 87% of respondents said they address prior authorization issues at least once per week, with nearly 3 of 4 (75%) noting that they can spend up to 60 min addressing each request. The burden on patients and practices is heavy, and physicians and practice managers are looking to organizations like the ACC to help enact change (2).
Nearly all (95%) of the cardiologists who responded to the ACC’s survey expressed that they would like the ACC to play a role in easing the burden of providing medication pre-authorization and documentation and overcoming insurance denials, and the College is doing just that. The ACC has long been a leader in efforts to find a solution that balances the needs of physicians and their patients with those of health plans. In 2005, the ACC debuted its first set of appropriate use criteria (AUC), which define “when to do” and “how often to do” a given procedure in the context of scientific evidence and expert consensus, the health care environment, the patient’s history, and a physician’s judgment. These criteria are intended to help physicians, policymakers, payers, and other medical societies ensure that patients are receiving the most appropriate care, while also reducing unnecessary health care costs and limiting wide variations in care delivery (3). Unfortunately, more than three-quarters (78%) of denials issued conflict with ACC’s AUC according to cardiologists in the ACC survey (2).
Furthering the ACC’s commitment to finding a solution to prior authorization issues, the ACC has joined other members of the medical community to demand changes to prior authorization requirements. The College joined a coalition led by the AMA to develop a set of 21 principles that seek to improve prior authorization and utilization management programs. The principles are centered around guaranteeing that any requirements are clinically valid and evidence-based, maintain continuity of care, are transparent and fair, allow patients timely and efficient access to drugs and treatments, and clearly articulate alternatives and exemptions (4). Another important element of prior authorization reform is the need for standardized processes for physicians and practice managers, as the current environment is burdened with varying processes for tests, devices, drugs, and more.
States like Ohio, Delaware, and Washington have begun to pass legislation and regulations to increase prior authorization transparency and standardize the approval and denial processing for requests. In Ohio, insurers must now disclose all prior authorization rules to providers, and enrollees of the health plan must receive basic information about which drugs and services will require prior authorization. The law also requires faster time frames for prior authorization decisions for urgent/nonurgent situations and prohibits retroactive denials regarding coverage or medical necessity, as long as the procedure was performed within 60 days of receiving an authorization (5). In Washington state, the Office of the Insurance Commissioner adopted regulations to streamline the marketplace’s prior authorization minimum standards and ensure that they are more transparent for consumers and providers (6). Like Ohio, the Delaware prior authorization law sets to increase transparency of the approval guidelines and timelines along with mandating electronic standards for pharmaceutical requests (7).
Other states, including Pennsylvania have introduced or are in the process of introducing similar legislation to promote the objectives to increase transparency, standardize the request processing and timing, and mandate the use of electronic forms. Several ACC state chapters are taking an active role in sharing our concerns about the current prior authorization system and opportunities to make these important changes.
These actions are directly protecting patients from overly burdensome requirements and practices from onerous administrative tasks that hinder time spent on direct patient care, and these examples could provide a blueprint for other states looking to make prior authorization more transparent and patient-centered.
Although there has been some meaningful change in this area, there is much work to be done to protect patient access to care and lessen the burden on practices. The ACC is working to be a part of this solution and convened the Prior Authorization Work Group. The 3 key elements of this work group were to promote acceptance of the ACC AUC as a tool for prior authorization, streamline the review/appeal process for requests outside of the AUC, and to stop test substitutions. The use of an ACC point of care tool to help in test selection and assessing appropriateness has been successfully used in Delaware and parts of Pennsylvania. This has resulted in lower but more appropriate and cost-effective resource utilization without the burden of prior authorization.
What can you do and how can we monitor the burden of prior authorization? The ACC is seeking input directly from practices on incorrectly denied or difficult prior authorization requests via the new web-based prior authorization tool (PARTool). The tool collects data to help the College determine overall prior authorization and test substitution trends, and to better understand problematic areas of the prior authorization process including time burdens, test substitution, and peer-to-peer reviews. The College will use the data garnered from responses to the 12-question form to share trends with insurers, prior authorization vendors, state legislators, and insurance officials to engage them in working to reduce the burden of prior authorization. The goal is to reduce the burden of prior authorization on ACC members, and to return attention to direct patient interaction. Practices can submit their issues via the simple online form at www.acc.org/PARTool.
This is 1 piece in the puzzle to find an answer to prior authorization challenges. However, to be successful on a larger scale for the entire medical community, insurers, physicians, care team members, practice administrators, and lawmakers need to work together to find a solution that ultimately saves time, saves money, and—most importantly—saves lives.
- 2017 American College of Cardiology Foundation
- ↵American Medical Association. 2016 AMA prior authorization physician survey. Available at: https://www.ama-assn.org/sites/default/files/media-browser/public/government/advocacy/2016-pa-survey-results.pdf. Accessed July 19, 2017.
- ↵American College of Cardiology. Barriers to new medications for cardiovascular disease: insights from CardioSurve. Available at: http://www.acc.org/latest-in-cardiology/articles/2017/02/21/12/42/barriers-to-new-medications-for-cardiovascular-disease-insights-from-cardiosurve. Accessed July 19, 2017.
- Shor R.
- ↵American Medical Association. Prior authorization and utilization management reform principles. Available at: https://www.ama-assn.org/sites/default/files/media-browser/principles-with-signatory-page-for-slsc.pdf.pdf. Accessed July 19, 2017.
- ↵Ohio State Medical Association. Prior authorization reform bill signed into law. Available at: https://www.osma.org/Public-Affairs/News/Prior-Authorization-Reform-Bill-Signed-into-Law. Accessed July 19, 2017.
- ↵Kreidler M. Prior authorization process: concise explanatory statement. June 5, 2017. Available at: https://www.insurance.wa.gov/sites/default/files/documents/2016-19-ces.pdf. Accessed July 19, 2017.
- ↵Delaware General Assembly. House Bill 381. 148th General Assembly (2015–2016). Available at: https://legis.delaware.gov/BillDetail?legislationId=24639. Accessed July 19, 2017.