It’s time to reform prior authorization to protect access to care

Help is on the way for doctors and patients burdened by health insurance red tape — but there’s still work to be done.

The Centers for Medicare and Medicaid Services (CMS) recently finalized a new rule that will bring the prior authorization policies of Medicare Advantage plans in alignment with Fee-for-Service Medicare. This is great news for the millions of Americans who rely on Medicare Advantage to cover their care — but are increasingly frustrated by insurance barriers.

The final rule echoes congressional efforts. Last Congress, the House of Representatives unanimously passed the Improving Seniors’ Timely Access to Care Act to help streamline and standardize prior authorization in the Advantage program. The ideas included in the bipartisan legislation, which was endorsed by nearly 500 patient, provider and other advocacy organizations, provide a road map for protecting patients from access barriers. Even though the Senate did not to take up the legislation, momentum on this issue is building. As CMS considers a new rule about electronic prior authorization, it is time to go farther to ensure timely decisions and appropriate transparency over the process.

Prior authorization is increasingly disrupting patient care in the U.S. According to a survey of physicians by the American Medical Association, 94 percent of physicians report care delays due to prior authorization, with 56 percent reporting that delays happen “often” or “always.” An astonishing 80 percent of doctors surveyed say that the process can at least sometimes lead to a patient abandoning their treatment. Moreover, one-third of physicians report that prior authorization has led to a serious adverse event for a patient in their care.

As insurers step up their use of prior authorization, patients are feeling the pain. A Kaiser Family Foundation study found that Medicare Advantage plans issued more than 35 million prior authorization requests in 2021. More than 2 million of these requests were fully or partially denied. Yet, when appealed, a majority of these denials (82 percent) were fully or partially overturned, suggesting the insurers should have approved them in the first place.

Virtually every specialty is impacted by prior authorization, from behavioral health and rheumatology to oncology and radiology.

My specialty, ophthalmology, has been subjected to egregious prior authorization abuse. Aetna’s Medicare Advantage policy requires prior authorization for all cataract surgeries in Georgia and Florida. Cataract surgery is a routine procedure that restores people’s sight. Prior authorization is meant to apply to expensive or experimental treatments that may need further review to ensure medical necessity. It’s not meant for established procedures like cataract surgery, a procedure that some 4 million Americans undergo each year to improve their quality of life. Humana’s Medicare Advantage plans have a similar policy for cataract surgery in Georgia.

While prior authorization expands, insurers are becoming more profitable. Insurers offering Medicare Advantage plans report significantly higher profit margins per enrollee than insurers in other markets. While Medicare Advantage patients face potentially dangerous delays in access to care, these insurers are boosting their profits by billions of dollars. Some wonder if that is why Humana plans to exit the commercial market to focus exclusively on Medicare Advantage.

More needs to be done at the federal policy level, not just for the 30 million older adults and patients with disabilities covered by Medicare Advantage, but for all patients.

Moving forward, policymakers should build on existing regulations by establishing electronic prior authorization mechanisms that provide real-time decisions for items and services that are routinely approved. It would also be helpful to patients if Medicare Advantage plans were required to be more transparent about their prior authorization decisions. Patients would also benefit by establishing a deadline for providing prior authorization decisions to no more than 24 hours from the time it is submitted. As policymakers consider next steps, the nation’s ophthalmologists will continue to work for a future in which patients’ eye care is not compromised.

Dan Briceland, M.D., is the president of the American Academy of Ophthalmology.