The American College of Rheumatology (ACR) has released an official position statement concerning prior authorization (PA) for the approval of prescription medications, highlighting the significant burden it creates for patients and rheumatology professionals. This process can result in a significant delay of care or treatments, treatment abandonment, and potential harm to patients, according to the ACA.

“In addition to creating additional hoops for patients and providers to jump through, (PA) diverts valuable time away from caring for patients and towards repetitive and time-consuming administrative tasks,” said Virginia Reddy, MD, the statement’s lead author and member of the ACR’s Committee on Rheumatologic Care, in the association’s press release. “For patients with complex conditions like rheumatic disease, these delays may last weeks or even months and can be the difference between successful treatment or permanent joint damage and disability.”

The ACR emphasizes the need to modernize and simplify the PA process with 5 key areas of improvement to ensure to care for patients:
 
  • Reduce the number of rheumatologists and rheumatology professionals subject to PA requirements by not requiring PAs if they are already meeting performance measures, adhering to evidence-based practices, and/or participating in a value-based agreement with a health insurance provider.
  • Reduce the number of services and medications that require PA by regularly reviewing and eliminating requirements that are no longer warranted.
  • Improve transparency and channels of communication between health insurance providers, health care professionals and patients to minimize delays in care and ensure requests are reviewed by qualified personnel with specialty-specific credentials. Further, rationales for denials should be provided in a timely and transparent manner.
  • Protect the continuity of care when there are changes in coverage, health insurance providers, or PA requirements. The goal is to ensure there is no interruption of care for patients who are on an ongoing, active treatment or a stable treatment regimen.
  • Accelerate industry adoption of national electronic standards for PA and improve transparency around formulary decisions and coverage restrictions at the point of care.

PA is used by insurance companies to control plan members’ access to specific pharmaceuticals and medical services. There is no uniformity in the PA requirements between different insurers, and the process frequently involves manually filling out multi-page forms for each patient for whom the provider has, through shared decision-making with the patient, determined that a particular pharmaceutical or service is the best treatment option.

A national survey including more than 1000 practicing physicians conducted by the American Medical Association (AMA) found that 75% of physicians reported that PAs can lead to patients abandoning recommended therapy and 91% believed that the PA process delayed patients’ access to care. Furthermore, the AMA survey revealed that the burden associated with PA has increased in the past 5 years.

According to an analysis of patient registry data conducted by the ACT, approximately 15% of patients in a typical rheumatology practice have rheumatoid arthritis and are treated with a medication requiring PA. For each of these patients, a rheumatologist or rheumatology professional must go through the PA process at least once per year due to insurance plan requirements that continuation of therapy be renewed annually.

Efforts to improve some elements of PA are underway in Congress, according to the ACR’s press release, including the Improving Seniors’ Timely Access to Care Act (HR 3107), a bipartisan bill sponsored by Reps. Suzan DelBene (D-WA), Ami Bera (D-CA), Mike Kelly (R-PA), and Roger Marshal (R-KS), which would require the Centers for Medicare and Medicaid Services (CMS) to regulate the use of PA by Medicare Advantage plans and establish a process to make real-time decisions for services that are routinely approved.

The legislation would also require plans to offer a process for electronic PA and to report to CMS how extensively they use PA and how often they approve or deny the relevant medications and services.

Reference
  1. ACR Releases Position Statement on Prior Authorization. American College of Rheumatology website. Published March 18, 2020. https://www.rheumatology.org/About-Us/Newsroom/Press-Releases/ID/1084. Accessed March 30, 2020.