AAFP to Congress: Pass Urgent Prior Authorization Reform

“With the growing role of Medicare Advantage, family physicians are concerned with the increasing number of administrative requirements that detract from time that would be better spent on patient care,” the AAFP said in its June 30 letter. “Family physicians report that prior authorization and other utilization management processes regularly cause patient care delays and can worsen health outcomes.”

The letter was sent to Reps. Diana DeGette, D-Colo., and H. Morgan Griffith, R-Va., chair and ranking member, respectively, of the House Energy and Commerce Committee’s Oversight and Investigations Subcommittee, in response to a hearing titled “Protecting America’s Seniors: Oversight of Private Sector Medicare Advantage Plans.” It was signed by Board Chair Ada Stewart, M.D., of Columbia, S.C.

In 2022, more than 28 million Medicare beneficiaries enrolled in a Medicare Advantage plan — some 45% of all Medicare beneficiaries. A burdensome prior authorization process is negatively affecting a significant number of these beneficiaries; an April 2022 HHS report found that, among prior authorization requests that Medicare Advantage plans denied in 2019, 13% actually had met Medicare coverage rules.

“The federal government needs to automate and streamline prior authorization, as well as reduce the overall volume of prior authorizations to improve patient care and minimize physician burden,” the AAFP said. “We know firsthand from family physicians that prior authorization creates an administrative burden for physicians and other clinicians. The manual, time-consuming processes used in prior authorization programs burden family physicians and their practice staff, divert valuable resources from direct patient care and can delay the start or continuation of necessary treatment, leading to lower rates of patient adherence to treatment and negative clinical outcomes.”

To support its case, the Academy pointed to an AMA survey in which 85% of responding physicians called the burden associated with prior authorization “high” or “extremely high” and said they and their staff spend almost two business days each week completing an average of 40 prior authorizations per physician. In the same survey, 30% of responding physicians reported that prior authorization had led to a serious adverse event for a patient in their care.

“To mitigate the impacts of prior authorization on patients and improve Medicare beneficiaries’ health outcomes, and to ease administration burden on physicians, we urge Congress to pass the Improving Seniors’ Timely Access to Care Act (H.R. 3173) and the GOLD CARD Act (H.R. 7995),” the Academy said. “These two bills will streamline the prior authorization process in Medicare Advantage plans by ensuring it is evidence-based, transparent and administratively efficient to protect patients from unnecessary delays in care, promote improved clinical outcomes and reduce administrative burden for physicians.”

The AAFP has endorsed previous versions of H.R. 3173. As part of a coalition of medical groups in 2019, the Academy underlined the urgency of prior authorization reform by citing a 2018 audit by the HHS Office of the Inspector General indicating that 75% of Medicare Advantage prior authorization denials over a two-year span (about 216,000 a year) were overturned.

To further bolster primary care access for Medicare Advantage beneficiaries, the Academy also urged Congress to strengthen the program’s network adequacy, complementary to a rule that CMS finalized this year, following the AAFP’s advocacy.