Do you feel as though you are spending more of your precious working time on hold, waiting to talk with a so-called peer from a patient’s health plan so that you can ensure the patient can get the medicine or procedure you know they need?
Sadly, you are not alone.
A solid majority of physicians—61%—report that they at least sometimes have to participate in “peer-to-peer” reviews to get approval for a medication or procedure they say is medically necessary for their patient, according to data from the most recent AMA prior authorization survey of 1,000 practicing physicians (PDF).
And it appears to be getting worse, with 56% saying that the number of peer-to-peer reviews they must do as part of prior authorization has risen over the past five years.
While that diverts a physician’s time away from patient care, what is equally frustrating for doctors is that the “peer” from the insurance company is often a peer in name only.
Just 15% of physicians surveyed said that the health plan-appointed peer “often” or “always” has the appropriate qualifications. More than one-third of physicians said that payer peers “rarely” or “never” have the expertise required to make a call on their patient’s prior authorization.
That means, for example, that a breast oncologist could end up talking to a “peer” who is an ob-gyn and unfamiliar with the nuances of treating breast cancer. Sometimes, the peer isn’t even a physician.
AMA President Bruce A. Scott, MD, an otolaryngologist in private practice in Louisville, Kentucky, is all too familiar with the frustration of not being able to speak to a physician who understands his specialty.
“I sit down with a patient, listen to their history, do a thorough exam, review imaging studies and then together we decide on a treatment plan,” Dr. Scott wrote in an AMA Leadership Viewpoints column. “But then I have to get approval from an insurance company representative who has never seen my patient and who typically isn’t even a physician. Never mind an otolaryngologist who could best understand the prescribed course of treatment; it’s rare the person on the other line can even pronounce otolaryngology.”
The AMA is fixing prior authorization by challenging insurance companies to eliminate care delays, patient harms and practice hassles.
Why it matters
Physicians must be able to quickly connect with a doctor who practices in the same specialty they do, because getting a peer-to-peer review with a medical expert who understands a patient’s condition and the medically appropriate treatments can truly be a matter of life and death.
Former AMA president Barbara L. McAneny, MD, an oncologist, had a patient with breast cancer that had spread to the spinal fluid around the brain. Placing a device into the brain so the chemotherapy can be injected directly into that area is the best way to treat the condition.
Dr. McAneny sent her patient to the neurosurgeon to have the device implanted, but the insurer refused to give the neurosurgeon permission to perform the procedure, calling it “experimental.” The patient’s care was delayed while Dr. McAneny tried to appeal.
“I could not get past the bureaucracy to get another physician to explain that this procedure is: A, lifesaving; and B, is definitely not an experimental procedure,” Dr. McAneny said in a moving video that is part of a collection of AMA member physicians sharing their awful experiences with prior authorization in practice.
In fact, the AMA’s prior authorization survey showed that among physicians surveyed:
- 94% said that the prior authorization process always, often or sometimes delays patients’ accessing necessary care.
- 19% said prior auth resulted in a serious adverse event leading to a patient being hospitalized.
- 13% said prior auth resulted in a serious adverse event leading to a life-threatening event or requiring intervention to prevent permanent impairment or damage.
- 7% said prior auth resulted in a serious adverse event leading to a patient’s disability, permanent bodily damage, congenital anomaly, birth defect or death.
The AMA advocates critical national and state-level reforms that must be made to improve prior authorization, including gold-carding programs, making prior authorization valid for the length of treatment for those with chronic conditions, and requiring that new health plans honor a previous payer’s prior authorization for a minimum of 90 days.
Find out more with the AMA about why fixing prior authorization means giving doctors a true peer to talk with—stat.
Among the measures the AMA supports is the Improving Seniors’ Timely Access to Care Act of 2024 (H.R. 8702; S. 4532), which is bipartisan and bicameral federal legislation that would reform prior authorization procedures in Medicare Advantage.
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