• AAFP Calls for Comprehensive Prior Authorization Reform

    Electronic Prior Authorization Alone Is Insufficient, Academy Tells HHS

    March 24, 2022, 5:21 p.m. News Staff — In new advocacy for administrative simplification this month, the Academy called for comprehensive prior authorization reform and objected to any federal mandate that physicians use electronic prior authorization.

    Hand writing "simplify" in blue marker

    The AAFP’s March 22 letter asked HHS “to increase oversight of prior authorization, reduce the volume of prior authorizations, increase transparency of prior authorization requirements and streamline prior authorization processes.” These interventions are urgently needed “to address the negative impacts prior authorizations are having on patients and physicians,” the Academy added, noting particular concern for how the process creates care barriers for patients of color, LGBTQ+ patients, patients in rural areas and those at risk for poor health outcomes.

    The letter cautioned, however, that such action shouldn’t be limited to automation and must not include a requirement that clinicians use electronic prior authorization.

    “Electronic prior authorization is just one step in addressing the flaws of utilization management practices,” the Academy wrote. “Comprehensive reform is needed to reduce the volume of prior authorizations and ensure patients’ timely access to care.”

    Making electronic prior authorization compulsory, meanwhile, would dramatically diminish incentives for payers and certified EHR technology vendors to solve existing paperwork burdens while further disrupting practices, the Academy said.

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    “Not only do these requirements negatively impact practice workflows and physician well-being, but evidence also shows prior authorization can harm patients by delaying care, confusing patients and resulting in reduced adherence to treatment or even discontinuation of treatment, all resulting in increased morbidity and mortality.”

    The Academy was responding to a request for information titled “Electronic Prior Authorization Standards, Implementation Specifications, and Certification Criteria,” published Jan. 24 in the Federal Register by HHS and the Office of the National Coordinator for Health IT. The letter was sent to HHS Secretary Xavier Becerra and ONC National Coordinator Micky Tripathi, Ph.D., M.P.P. It was signed by AAFP Board Chair Ada Stewart, M.D., of Columbia, S.C.

    The advocacy marks the latest salvo in the Academy’s push for administrative simplification, echoing previous calls for regulators to reform and streamline a prior authorization process that family physicians cite among their most burdensome tasks.

    “Prior authorization requirements have grown over the years and throughout the COVID-19 pandemic, exacerbating barriers to care during this challenging time,” the letter said, citing a recent poll of medical groups in which 81% of respondents said prior authorization requirements had increased since 2020. In a 2021 AMA survey linked in the letter, 88% of responding physicians said prior authorization had generated high or extremely high administrative burden for their practices.

    “Practices complete an average of 41 prior authorizations per physician per week (and) spend an average of almost two business days a week completing prior authorizations,” the AAFP wrote. “What’s more, the burden from increased requirements is compounded by the labor shortage coinciding with the pandemic, which has affected practices’ ability to recruit and retain practice staff and appropriately complete prior authorization requests.”

    The letter added that, for patients, prior authorization requirements may be discriminatory and worsen health disparities, according to research, with minority and underserved populations disproportionately affected.

    The Academy further urged HHS and ONC to

    • ensure that prior authorization and other utilization management review processes covered by health IT functionality certification are clinically valid, fair, transparent and efficient;
    • make information related to prior authorization requirements and documentation readily available to the ordering physician;
    • use only standards and implementation guides that have been proven effective and adoptable in real-world testing, including the Da Vinci standards; and
    • establish guardrails for how payers can use data pulled for prior authorizations.

    The letter also asked HHS to factor practices’ expenses into any new electronic prior authorization policy.

    “Physicians are dependent on their EHR vendors to provide the functionality and on payers to adopt the standards so they can be used to fulfill prior authorization requirements,” the letter said. “To optimize the adoption of future standards, we urge ONC to minimize the costs that can be passed on to physician practices when they are updating their EHRs to implement new prior authorization standards.”