• AAFP to House Small Business Committee: Mandatory Prior Authorizations For Needed Medical Services Delays Care, Increases Costs


    Wednesday, September 11, 2019

    Leslie Champlin
    American Academy of Family Physicians

    WASHINGTON — Prior authorizations for diagnostic procedures, prescriptions and durable medical equipment should be dramatically reduced or eliminated because they pose a significant threat to high-quality patient care and efficiency in medical practice, according to the American Academy of Family Physicians.

    In written and verbal testimony today before the House Small Business Committee hearing on barriers to care and burdens on small medical practices, AAFP President John Cullen, MD, called for a standardized and automated prior authorization process throughout the health care system. Moreover, prior authorization requirements should not be required for successful, ongoing treatment of chronic conditions. Those policy changes would ensure patients have timely access to needed care and reduce costly administrative work in physician offices, he said.

    “While there may be a limited number of justifiable cases where prior authorization is appropriate, it is clear that health plans more often require prior authorization as a cost-containment strategy by limiting and restricting access to specific services,” Cullen told the committee, noting that after constantly grappling with prior authorizations in his practice, none of his requests have been denied.

    Family physicians in private practice have contracts with seven or more health insurance plans, and they must navigate the maze of those plans’ administrative requirements. The administrative complexity — and its harm to patient care — is most apparent in prior authorizations for prescriptions, durable medical equipment and diagnostic services, according to Cullen.

    Much of the problem stems from having to know which medications are preferred for each health plan, particularly since insurers frequently change the preferred medication list, he added.

    “Securing prior authorization for tests, devices, medications, treatments, or procedures often delays the patient’s access to necessary care,” he said. “Appealing a denied request for prior authorization can significantly add to those delays. In a 2018 American Medical Association survey, nearly two-thirds of physicians reported waiting at least one business day to receive prior authorization, while 26 percent waited at least three business days. Further, 28 percent of those surveyed reported the prior authorization process lead to a serious adverse event.

    “This is especially true regarding the health of patients with chronic disease receiving ongoing treatment. Their health should not be threatened by the patient changing health plans. Patients should not be required to repeat or retry step therapy protocols failed under previous benefit plans. Payers should be prohibited from requiring repeated prior authorizations of effective medication management for such patients.”

    The AAFP called on lawmakers to adopt policies that address the complexity by:

    1. Standardizing and automating prior authorizations via electronic systems to promote efficiency and reduce administrative burdens.
    2. Ending mandatory step therapy for patients already on a course of treatment; allowing continuation of ongoing care while prior authorization approvals or step therapy overrides are obtained.
    3. Eliminating prior authorizations for generic medications.
    4. Simplifying rules on prescription of diabetic supplies to encompass syringes, needles, test strips, lancets, glucose testing machines and other necessary supplies and to enable the prescription to be good for the patient’s lifetime.
    5. Exempting physicians who participate in alternative payment models from all prior authorization requirements.

    “We strongly support policy initiatives to eliminate or reduce and streamline prior authorization procedures and these should be aligned and harmonized across all payers – public and private,” Cullen told the committee. “By taking steps to standardize and automate prior authorization processes and requirements across the health care system, this will help minimize restrictions that prohibit timely access to medically necessary care.”

    Cullen’s testimony comes on the heels of AAFP’s September 6 endorsement of the Improving Seniors’ Timely Access to Care Act of 2019 (HR 3107), which would help protect patients from unnecessary delays in care by streamlining and standardizing prior authorization under the Medicare Advantage program, providing much-needed oversight and transparency of health insurance for America’s seniors.


    About American Academy of Family Physicians
    Founded in 1947, the AAFP represents 127,600 physicians and medical students nationwide. It is the largest medical society devoted solely to primary care. Family physicians conduct approximately one in five office visits -- that’s 192 million visits annually or 48 percent more than the next most visited medical specialty. Today, family physicians provide more care for America’s underserved and rural populations than any other medical specialty. Family medicine’s cornerstone is an ongoing, personal patient-physician relationship focused on integrated care. To learn more about the specialty of family medicine and the AAFP's positions on issues and clinical care, visit www.aafp.org. For information about health care, health conditions and wellness, please visit the AAFP’s consumer website, www.familydoctor.org.