As health care continues to shift toward a more patient-centered model, patients are playing an increasingly active role in the development of their own individualized treatment plans. Utilization management programs, such as prior authorization, may interrupt or delay medical services, divert significant resources from patient care and complicate medical decisions, creating time-consuming and unnecessary obstacles for health care providers implementing patient-centered care.

In response to unreasonable hurdles for patients seeking care, ACC has partnered with the American Medical Association (AMA) and 15 other health care organizations to create a coalition advocating for the reform of prior authorization requirements imposed on medical tests, procedures, devices and drugs. The coalition represents a wide range of health care industry stakeholders, including physicians, hospitals, medical groups, patients and pharmacists, all of whom oppose required pre-approval from insurers before patients can get certain drugs or treatments.

In a recent survey from the AMA, almost 90 percent of surveyed physicians reported that prior authorization sometimes, often or always delays access to care, and 75 percent described the burdens of prior authorization as high or extremely high. More than one-third of surveyed physicians reported having staff who exclusively work on prior authorization, and nearly 60 percent of those surveyed reported that their practices wait an average of one business day for prior authorization decisions.

Due to these burdens, the coalition is calling for an industry-wide reassessment of prior authorization. To guide the reassessment and reform process, the coalition created a set of 21 principles emphasizing the application of concepts grouped into five broad categories: clinical validity, continuity of care, transparency and fairness, timely access and administrative efficiency and alternatives and exemptions.

“Strict or bureaucratic oversight programs for drug or medical treatments have delayed access to necessary care, wasted limited health care resources and antagonized patients and physicians alike,” said AMA President Andrew W. Gurman, MD. “The AMA joins the other coalition organizations in urging health insurers and others to apply the reform principles and streamline requirements, lengthy assessments and inconsistent rules in current prior authorization programs.”

Patient-centered care is a common goal across the health care industry. ACC welcomes the opportunity to work collaboratively with the coalition to reduce prior authorization’s negative impact on patients, providers and the health care system. The coalition strongly urges health plans, benefit managers, accreditation organizations, and other parties conducting utilization management to apply the 21 principles to utilization management programs. Adherence to these principles will ensure that patients have timely access to treatment and reduce administrative costs to the health care system.

Keywords: Accreditation, American Medical Association, Continuity of Patient Care, Efficiency, Organizational, Health Care Coalitions, Health Care Sector, Insurance Carriers, Insurance, Health, Patient Care, Patient-Centered Care, Pharmacists, Physicians

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