Prior authorization is a cost-control tactic requiring physicians to obtain approval from health insurance companies before treatments qualify for coverage. This administrative process exacerbates care delays and has been criticized as a “medical injustice disguised as paperwork” that benefits insurers at the expense of patient well-being.

“Across the country, physicians see firsthand the dangerous, harmful—and sometimes deadly—consequences of prior authorization,” wrote AMA President Bruce A. Scott, M.D., in a viewpoint accompanying the AMA survey. “Payers erect roadblocks and hurdles allegedly designed to save money for the health system and protect precious resources, but when patients and their doctors face care delays—or even give up and abandon necessary care—the result can actually be increased overall costs when worsening health conditions force patients to seek urgent or emergency treatment. Our patients are caught in the middle, twisting in the wind, while physicians fight for them, often with fax machines as our only available weapon.”

The AMA survey results highlight that delayed and disrupted care has become a common experience for patients due to widespread use of prior authorization programs by the health insurance industry.

Key findings from the survey include:

- Nearly one in four physicians (24%) reported that prior authorization has led to a serious adverse event for a patient, including hospitalization, permanent impairment, or death.

- More than nine in 10 physicians (93%) reported that prior authorization negatively impacts patient clinical outcomes.

- More than nine in 10 physicians (94%) stated that prior authorization delays access to necessary care.

- Over three-fourths of physicians (78%) indicated that patients abandon treatment due to authorization struggles with health insurers.

- More than half of physicians (53%) noted that prior authorizations had impeded a patient's job performance.

Physicians also reported significant administrative burdens when complying with prior authorization requirements across major health plans:

- Physicians completed an average of 43 prior authorizations per week; more than a quarter (27%) stated these requests are often or always denied.

- Prior authorization requirements consume approximately 12 hours of physician and staff time each week per physician. Over a third (35%) employ staff members exclusively for tasks related to prior authorizations.

- More than nine in 10 physicians (95%) reported that prior authorization increases physician burnout.

Additionally, the survey found that prior authorizations lead to significant waste and added costs within the healthcare system:

- Over four in five physicians (87%) indicated that these requirements lead to higher overall utilization of healthcare resources rather than cost-savings. Resources were diverted to ineffective initial treatments (69%), additional office visits (68%), urgent or emergency care (42%), and hospitalizations (29%).

Despite evidence highlighting these issues, progress on voluntary reforms agreed upon by national organizations representing pharmacists, medical groups, hospitals, and health insurers remains insufficient. Consequently, the AMA advocates for state-level reforms and supports federal legislation aimed at reforming Medicare Advantage's prior authorization procedures through the Improving Seniors’ Timely Access to Care Act of 2024.

“The time is now for Congress to adopt reintroduced prior authorization reform legislation that prioritizes patients’ access to care reduces administrative burdens on physicians and preserves resources for high-quality care,” said Dr. Scott. “Because insurers will not change their ways despite their rhetoric, lawmakers have an important opportunity to rein in excessive prior authorization requirements and unnecessary administrative obstacles between Medicare Advantage patients and evidence-based treatments.”

The AMA continues efforts to streamline prior authorization programs so that physicians can focus on patient care rather than administrative duties. Patients, physicians, and employers can learn more about reform efforts at FixPriorAuth.org.