February 2, 2023

Breaking Through the Red Tape

By John Gallagher

Editors' note (Dec. 5, 2024): We are republishing this archived WSMA Reports cover story as part of our Your Care Is at Our Core campaign to highlight the impact excessive prior authorization practices have on patient care. While some progress has been made since this story was written, much of the problems outlined in the article remain a fact of life for physicians and patients today, and physicians continue to fight these practices to help ensure their patients receive needed and timely care.

Imagine a process that delayed needed care, relied on outdated technology, and drove up costs for physician practices and patients, yet in the vast majority of cases led to no change in the course of treatment. As it turns out, you don't have to imagine. That process exists: prior authorization. From the administrative burden it places on physicians to the harm it causes to patients, prior authorization has transformed from a process ostensibly established to reduce overuse of resources into one that diverts an enormous amount of time and resources better spent on patient care.

"In the past 15 years, it's been getting worse and worse," says Katina Rue, DO, a family physician in Kennewick and president of WSMA. "Maybe there was a good reason when it began, but now it's snowballed into a giant entity. Physician practices are having to hire additional staff, retrain current staff, and pull physicians from patient care to deal with it."

Indeed, a 2021 physician survey by the American Medical Association documented just how extreme the burden of prior authorization is on both physicians and patients. On average, the 1,000 physicians surveyed completed 41 prior authorizations every week, spending an average of two days on the process. Forty percent of physicians have staff who exclusively complete prior authorizations. Fully 88% of the physicians said that prior authorizations represented a high or extremely high burden.

The 2021 survey underscores that the problem of prior authorizations is only getting worse. An AMA survey from 2017 found doctors completing four fewer prior authorizations a week and just over one-third of them with staff fully dedicated to the process.

Recognizing the concerns of its members, the WSMA is making prior authorization reform its top priority in the 2023 Washington state legislative session. But reforming prior authorization won't be easy and it won't happen overnight.

"This is going to be an ongoing priority," said Sean Graham, WSMA's director of government affairs. "We're in it for the long haul. We're committed to engage on this issue until we see meaningful improvement."

Opaque processes and antiquated technology

Every physician has stories to tell about how prior authorizations make caring for patients unnecessarily hard. To begin with, it's impossible to tell what will require prior authorization. Each carrier has its own rules and formularies, with the formularies sometimes changing at the start of the year. Physicians don't know what will require prior authorization until the insurance company rejects a prescription or request for a procedure, frustrating both physician and patient.

For specialists, prior authorization is pretty much a given. Amish Dave, MD, a rheumatologist at Virginia Mason Franciscan Health, says that in his specialty, "most of our medications are biologics that are super expensive and almost all require prior authorization, not dissimilar to what oncologists and other specialists deal with." At this point, Dr. Dave says, even inexpensive medications are routinely subjected to prior authorization.

Once a request is denied, the effort to get approval begins. The process is onerous enough, but it relies on outdated technology. At a time when medical systems are dependent upon electronic health records, prior authorization systems are dependent on fax machines.

"It's bizarre that we're living in the 21st century and relying on faxes and hoping that they get it," says Dr. Dave.

Because faxes can't be tracked the way an electronic exchange can, missed faxes and their attendant delays are all too common. "I can't tell you how many times faxes don't arrive for whatever reason," says Clinton Hauxwell, MD, a family physician at MultiCare in Spokane.

The plans have a "peer-to-peer" process that, at least in theory, can match physicians with a knowledgeable colleague who can evaluate their case. However, the "peer-to-peer" part often fails to live up to its billing.

"It's frequently somebody who knows less about the study than I do," says Dr. Hauxwell. "Not to say anything about the person on the other end of the line, but they're just reading the script."

Dr. Dave says that his prior authorization questions about rheumatology cases are rarely handled by a rheumatologist. "I have had people with ANCA [anti-neutrophil cytoplasmic autoantibody] vasculitis, where they literally have an organ-threatening disease and I want to get them on rituximab," he says. "Instead of getting a peer, I get a pharmacist or a pediatric occupational medicine doctor who deals with disability cases and knows something about seminal trials. It's demeaning because you are talking to someone who has the power to deny the medicine you've been waiting weeks for, and then you talk to someone who is not even a peer."

Indeed, prior authorization now treats every physician with the same level of suspicion, even if most physicians have their requests routinely approved. Essentially, health plans are casting the widest possible net to catch a few outliers.

"My experience with prior authorization for imaging studies that require peer- to-peer review is that they always get approved because it's appropriate order," says Dr. Hauxwell. "But the time I and my staff spend is inordinate."

Risking patient safety and access to care while contributing to burnout

The waste of time and resources is just part of the problem with the current prior authorization system. The bigger one is the impact it has on patients and physicians.

"My biggest concern is that due to its ever-increasing reach, it is actually now a patient safety issue," said Carrie Horwitch, MD, an internist at Virginia Mason Franciscan Health. "It is causing harm to patients by delaying care or even perhaps denying appropriate care."

The AMA physician survey bears that observation out. Over a third of physicians reported that prior authorization led to a severe adverse event for a patient, while 24% indicated prior authorization led to a patient's hospitalization.

As a primary care physician with a large HIV practice, Dr. Horwitch regularly runs into the prior authorization wall when she prescribes antiretrovirals for patients. "They are considered a specialty medication," she notes. "They are more expensive and typically a higher tier. I have experienced delays in getting approval when I need to start someone on medication or perhaps need to change someone to an antiretroviral that is better or safer for them. These are medications that shouldn't be delayed because they lead to better outcomes and reduced transmission."

The problem is hardly confined to just HIV medications. "The other big area that many, many physicians and allied health professionals face with patients is diabetes," Dr. Horwitch says. "I think everyone has run into delayed or denied care, which could include insulin or the type we want to prescribe, or the new medications, which evidence shows may be better or safer for patients with multiple comorbidities than some of the older medications."

Prior authorization denials hit some types of patients harder than others. A 2021 report on prior authorization from the Washington state Office of the Insurance Commissioner found that carriers reported a lower number of requests, approval rates, and response times for mental health-related codes.

One frequent frustration is the tiering system for drugs. Sometimes patients fail on the first treatment, but instead of their physician being able to move them to a medication with a different method of action, they are denied access to that medication until they try another medication like the first failed treatment.

"We know it didn't work for that first drug, and then they make someone suffer for no reason because you want them to try a cheaper medicine first," says Dr. Dave. Instead, the patient bears the financial cost of the failed second treatment, as well as the additional physical cost of the failed therapy before being able to get the right medication.

Dr. Dave brings a unique perspective on prior authorization because for six years he used to do prior authorizations for a small pharmacy benefit management company. "There is a real role for prior authorization, and I understand that perspective," he says. Yet what he saw was that inappropriate use was a problem "less than 10% of the time," far smaller than the current prior authorization apparatus would justify.

If anything, Dr. Dave says, physicians are trying to do right by their patients. "Most of the time, physicians are not trying to prescribe the wrong drug for their patients," he says. "They are not trying to prescribe something inferior or less effective just because it's cheaper."

The constant battle just to do the right thing inevitably takes a toll on physicians. Jack Resneck Jr., MD, president of the AMA, has said that prior authorization is high on the list of what he calls "hassle factors" contributing to physician burnout.

Dr. Dave agrees and points out that the burnout affects the relationship with patients. "One thing that is driving burnout for physicians is not just the increase in paperwork, but how the therapeutic alliance between patients and physicians is affected by these things," he says. "People think we are responsible for the delay in getting their treatment."

Burnout only contributes to the physician shortage, particularly in primary care. Yet the remaining physicians find more and more of their time consumed by prior authorization requirements.

"Now with physicians spending a large amount of time on prior authorizations instead of direct patient care, it's very directly impacting the access to patient care in Washington state," says Dr. Hauxwell. "It's time I could use to take care of patients. It adversely impacts patients' ability to have access to me, when I'm in a state that already has primary care access challenges."

Taking steps toward reform

Starting to tackle the many problems of prior authorization won't be easy. However, heading into legislative session, the WSMA is able to build on past successes, including a series of rulemakings from the insurance commissioner's office in 2015 and 2016, as well as legislation from 2020 that led to some reporting requirements on prior authorization practices.

"We're making this our top priority for the 2023 legislative session," says WSMA's Graham. "We are looking to standardize prior authorization as broadly as we can at the state level. We are looking to reduce the administrative burden and expedite access to care for patients who need health care services."

The WSMA is modeling its proposed legislation in part on a measure that was successfully passed last April in Michigan. Among the major components of the measure:

• Standardizing prior authorization requirements across state-regulated insurance carriers, mandating that insurance carriers utilize electronic portals, approve standard prior authorization requests within 48 hours, and approve expedited prior authorization requests within 24 hours.
• Promoting transparency by requiring insurance carriers to post their prior authorization requirements and all relevant evidence and criteria online, as well as making it available to patients and physicians upon request.
• Ensuring insurance carriers are making informed decisions on prior authorization by requiring determinations to be made by a physician or physician assistant in the same specialty as the ordering physician or physician assistant.
• Prohibiting the use of prior authorizations for those services that are routinely approved at high rates, building on legislation the WSMA spearheaded in 2020 to compel annual reporting on insurance carriers' prior authorization practices.

The Michigan legislation was the result of a three-year campaign. "We're hopeful that it won't take three years, but if that's what it takes, we're going to do it," says Graham.

However, there is only so much that some legislation will be able to do. One major exception to any state-level reform that passes will be self-insured plans, which most large employers carry. Under the federal Employee Retirement Income Security Act, or ERISA, self-insured plans would be exempt from any changes to prior authorization requirements enacted in legislation.

Efforts are also underway at the federal level to reform prior authorization. Last September, the House of Representatives passed a measure that would institute a number of changes for Medicare Advantage plans. The bill would establish an electronic process for prior authorization, forcing plans to move away from the antiquated fax and paper systems that many still require. The measure would also require Medicare Advantage plans to provide data to the Centers for Medicare and Medicaid Services on how frequently they require prior authorizations, as well as their rates of denials and approvals.

In an era of intense political polarization, the measure had broad bipartisan support, with 326 votes in favor of passage. "I think our legislation is a straightforward fix that will make a huge difference for patients and for [physicians]," Rep. Suzan DelBene (D-Medina), the bill's sponsor, told the AMA. Even DelBene's family hasn't been spared the problem. A parent of a family member had to cancel scheduled surgery because they were unable to receive prior authorization in time.

The WSMA has been actively supporting the federal effort, as well. Any reform that impacts Medicare could have wide-reaching implications.

"There's a saying - as Medicare goes, so goes the world," says Jeb Shepard, WSMA's director of policy. "Traditional Medicare doesn't typically require prior authorization. What is really compelling here is that these are Medicare Advantage plans, so they are insurance carriers. The hope is that these potential new requirements on Medicare Advantage plans would be adopted by the broader carrier market, including those self- insured ERISA plans. That is simply a hope at the moment, and time will tell."

Still, the momentum is moving toward change.

"This legislation is the first step," Dr. Rue says of the Washington state measure. "This is a long process. It's going to be a stepwise approach that takes many years. The insurance companies have held the narrative for a long time. Now it's going to take physicians working with patient groups and others to help move this forward. Hopefully, right now health care is in a space where we're trusted by legislators and the public."

John Gallagher is a freelance writer specializing in health care.

This article was featured in the January/February 2023 issue of WSMA Reports, WSMA's print magazine.