The Smart Medical Practice

Prior Authorization – Solo and Joint Efforts Take Aim at Healthcare’s Pre-authorization Problem


In the last post in this series, we reported on a pledge taken earlier this year by several payer and provider organizations aimed at improving the prior authorization process.

Another, similar effort is under way from the American Academy of Family Physicians (AAFP). It began with a resolution in September 2016 and, after being vetted, was adopted as an official policy in April 2017.

In the policy, AAFP says it believes prior notifications should be standardized and universally electronic through the industry. It describes prior authorizations as creating significant barriers for family physicians to deliver timely and evidence-based care by delaying the start or continuation of necessary treatment.

“The AAFP believes family physicians using appropriate clinical knowledge, training, and experience should be able to prescribe and/or order without being subjected to preauthorizations,” reads the policy. “In rare circumstances when prior authorizations are clinically relevant, the AAFP believes they should be evidenced-based, transparent, and efficient to ensure timely access and ideal patient outcomes. Additionally, family physicians that contract with health plans to participate in a financial risk-sharing agreement should be exempt from being required to obtain precertification.”

Finally, the policy states that generic medication should not require prior authorization and that step therapy protocols should not be mandatory for patients already on a course of treatment. Additionally, patient should not be required to repeat or retry step therapy protocols failed under previous benefit plans.

In the article announcing the new policy, AAFP says prior authorizations are the single most frustrating part of modern medical practice in the US.

In addition to creating the policy, AAFP joined with a 16-organization coalition aimed at urging health insurers and others to apply the reform principles and streamline requirements, lengthy assessments, and inconsistent rules in current prior authorization programs.

The coalition, which includes hospitals, medical groups, patients, pharmacists and physicians, created a set of 21 principles around clinical validity, continuity of care, transparency and fairness, timely access and administrative efficiency, and alternatives/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 Dr. Andrew Gurman. “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.”

Most recently, the AMA and Anthem announced they will work together to improve health care, including streamlining prior authorization. “Physicians caring for patients across the country have many ideas about how we can reduce health care costs and administrative burdens while improving clinical outcomes, and we need the collaboration of Anthem and all health plans to implement those strategies,” said AMA Board Chair Dr. Gerald Harmon.

Anthem’s chief clinical officer, Dr. Craig Samitt, said collaboration between physicians and payers is critical to evolve and advance the US healthcare system to one that is simpler, more accessible, and more affordable for consumers.


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