New AAFP Policy Takes Aim at Prior Authorizations

May 26, 2017 01:55 pm News Staff

What's the single most frustrating part of modern medical practice for U.S. physicians?

[Male doctor writing on chart in office]

Many family physicians would say the answer to that question is a cumbersome prior authorization process that stands in the way of getting patients the tests and treatments they need. And worse, the process itself eats away untold hours of valuable time -- be it that of physicians or their staff members.

In recognition of the overwhelming extent of the problem, the AAFP Congress of Delegates adopted a resolution on the topic  in September 2016 that was then referred to the Academy's Commission on Quality and Practice for further action.

After a thorough vetting, the AAFP Board of Directors voted in April to adopt an official AAFP policy on prior authorizations that members of the commission had developed.

The policy lays out in the first paragraph why fixing this problem is of critical importance to family physicians.

"Prior authorizations create significant barriers for family physicians to deliver timely and evidenced-based care to patients by delaying the start or continuation of necessary treatment," the AAFP states. "The very manual, time-consuming processes used in prior authorization programs burden family physicians, divert valuable resources away from direct patient care, and can inadvertently lead to negative patient outcomes."

To achieve the level of simplicity necessary to enable a busy medical practice to readily deal with this bothersome process, prior authorizations should be "standardized and universally electronic throughout the industry to promote conformity and reduce administrative burdens," says the AAFP.

Furthermore, family physicians "using appropriate clinical knowledge, training and experience," should, in most circumstances, have the freedom to prescribe and order what their patients need without being "subjected" to prior authorizations.

Recognizing that in certain rare instances prior authorizations are clinically relevant, the AAFP policy states the need for an evidence-based, transparent and efficient system "to ensure timely access and ideal patient outcomes."

In addition, prior authorizations should not be required of family physicians who contract with health plans to participate in a financial risk-sharing agreement. And prior authorizations aren't indicated when physicians prescribe generic medications for their patients, says the AAFP.

Step therapy protocols are particularly troublesome because they often delay a patient's access to treatment and hinder adherence, says the AAFP.

"Therefore, the AAFP maintains that step therapy should not be mandatory for patients already on a course of treatment. Ongoing care should continue while prior authorization approvals or step therapy overrides are obtained."

Finally, the AAFP maintains that a patient should not be asked to "repeat or retry step therapy protocols" that already failed when the patient was covered by previous benefit plans.

The Academy's recent action on prior authorizations came on the heels of a call by the AAFP and a coalition of 16 other organizations earlier this year to reform prior authorization and utilization management requirements.

The coalition published a document(www.ama-assn.org) titled "Prior Authorization and Utilization Management Reform Principles" that urged health insurers and others to apply the reform principles to current prior authorization programs.

Related AAFP News Coverage
2016 Congress of Delegates
Family Physicians Intent on Fixing Issues That Impede Patient Care

(9/26/2016)

Durable Medical Equipment, Prosthetics, Orthotics, Supplies
Final Rule Confirms Certain Items Will Require Prior Authorization

(1/13/2016)