A Survey of American Psychiatrists Concerning Medication Prior Authorization Requirements

Perceptions of prior authorization burden and solutions

The prior authorization (PA) process consumes time and money on the part of patients, providers, and payers. While some research shows substantial possible savings in the PA process, identifying what different groups can do is not as well known. Thus, organizations have struggled to capture this opportunity. To understand different perspectives on PA burden and receptivity to possible changes in the PA process, we surveyed 1005 patients, 1010 provider employees, and 115 private payer employees. Patients reported the longest perceived wait times but indicated the highest perceived approval rates and lowest perceived burden. The relatively low burden for patients is because most do not have to engage in PA directly. Provider respondents reported spending time equivalent of more than 100 000 full-time registered nurses per year on prior authorization. Artificial intelligence (AI) represents a possible solution: 65% of private payer respondents reported that their organizations planned to incorporate AI into the process in the next 3 to 5 years. Intended adoption by provider respondents is much smaller (11%). Private payer respondents cited cybersecurity concerns and a lack of technical infrastructure as barriers; provider respondents cited lack of budget and limited trust in the technology.

Potential US Health Care Savings Based on Clinician Views of Feasible Site-of-Care Shifts

Importance

Shifting care to alternative sites when clinically appropriate may be associated with reduced US health care spending, improved access, and, in some cases, improved care outcomes.

Objective

To fill 2 main gaps in the current literature on site-of-care shifts: (1) understanding the clinician perspective on appropriateness of alternative care sites, given the central role they play in referrals and patient trust and (2) considering all potential sites where care could shift and calculating net savings potential.

Design, Setting, and Participants

In this survey study, physicians (MDs and DOs), nurse practitioners, physician assistants, nurse anesthetists, radiology and imaging technicians, and psychologists were surveyed from September 17 to November 22, 2021, about potential shifts of care from the hospital setting to alternative sites. Participants were selected by the survey firm Intellisurvey to provide broad representation across all specialties of interest. A minimum of 34 clinicians responded to each question. Data were analyzed from April 2022 through October 2023.

Exposure

More than 5000 individual diagnostic and procedural codes were reviewed and sorted into 312 distinct care activities by an expert panel of physicians. Survey respondents were then provided with the 2019 claims-based distribution across sites of care for each care activity and were asked, "based on your clinical judgment, what portion of [care activity] could safely occur in each of the following sites of care, without compromising clinical outcomes?"

Main Outcomes and Measures

Based on clinician-reported distributions, the total potential shift of volume from hospital-based settings to alternative sites and the associated net savings were estimated.

Results

Survey respondents included 1069 practicing clinicians (386 female [36.1%]; mean [SD] years since residency of physicians, 21.0 [9.7] years; mean [SD] age of nonphysicians, 45.3 [9.4] years) across specialties, all of whom practiced more than 20 clinical hours per week. There were 794 physicians (74.3%), and the remaining 275 respondents were midlevel professionals, such as physician assistants. Among 312 care activities surveyed, respondents indicated that 10.3 percentage points (95% CI, 10.0-10.5 percentage points) of commercial and 10.9 percentage points (95% CI, 10.7-11.1 percentage points) of Medicare volume currently taking place in hospital-based settings could shift to alternative sites with today's technology without compromising clinical outcomes. Across the entire US health care system, these shifts could be associated with a reduction in overall health care consumption spending ($3 562 339 000 000 000) by approximately $113.8 billion ($113 767 446 087 174 [3.2%]) to $147.7 billion ($147 661 672 284 263 [4.1%]) annually.

Conclusions and relevance

In this study, a substantial net savings opportunity was estimated. However, realizing this potential will require ongoing alignment among organizations, clinicians, and policymakers to overcome barriers to these shifts.

Active steps to reduce administrative spending associated with financial transactions in US health care

US health care administrative spending is approximately $1 trillion annually. A major operational area is the financial transactions ecosystem, which has approximately $200 billion in spending annually. Efficient financial transactions ecosystems from other industries and countries exhibit 2 features: immediate payment assurance and high use of automation throughout the process. The current system has an average transaction cost of $12 to $19 per claim across private payers and providers for more than 9 billion claims per year; each claim on average takes 4 to 6 weeks to process and pay. For simple claims, the transaction cost is $7 to $10 across private payers and providers; for complex claims, $35 to $40. Prior authorization on approximately 5000 codes has an average cost of $40 to $50 per submission for private payers and $20 to $30 for providers. Interventions aligned with a more efficient financial transactions ecosystem could reduce spending by $40 billion to $60 billion; approximately half is at the organizational level (scaling interventions being implemented by leading private payers and providers) and half at the industry level (adopting a centralized automated claims clearinghouse, standardizing medical policies for a subset of prior authorizations, and standardizing physician licensure for a national provider directory).

Intentional Overdose Prevention in the Era of the 90-Day Prescription

The market share of 90-day prescriptions has risen dramatically in recent years, primarily because of increasing incentivization by insurers, pharmacies, and pharmacy benefit managers. Although 90-day prescriptions may benefit patients, they are potentially dangerous for those at risk for suicide. Prior authorization requirements by some insurers for coverage of shorter prescriptions and some pharmacists' newfound ability to unilaterally convert 30-day prescriptions with refills into 90-day supplies have complicated physicians' efforts to prevent harm to these patients. Here, the authors discuss the patient safety challenges posed by 90-day prescriptions and suggest potential mitigation strategies that would still preserve the benefits of larger medication supplies.

Oncology Trainee Perceptions of the Prior Authorization Process: A National Survey

Purpose

The medical trainee perspective regarding the prior authorization process has not been previously assessed. Here we evaluate the perceptions of radiation and medical oncology trainees regarding the prior authorization process and its effect on their training and patient care.

Methods and Materials

A 12-question, nonincentivized, electronic national survey of radiation and medical oncology trainees at all Accreditation Council for Graduate Medical Education accredited oncology programs was conducted. Participation, perspectives, and experiences with the prior authorization process were assessed by Likert scale, free response, and multiple response selection.

Results

Between January and March of 2019, the survey was distributed to 1505 trainees at 76 institutions with responses from 174/616 radiation (28.2%) and 139/889 medical oncology trainees (15.6%). The majority (69.2%) reported participating in the prior authorization process (radiation: 78.2% vs medical: 57.6%; P < .01). Most trainees (71%) reported concern for decline in the quality of patient care due to the prior authorization process. The majority of trainees (77.1%) reported decreased enthusiasm for work and choice of profession, with a higher incidence in medical oncology trainees (83.1% vs 73.7%, P = .04). The most commonly recommended modifications by trainees included that the insurance reviewer be in the same specialty as the ordering provider (87.7%), providers be compensated for participation (82.7%), and turnaround time be more rapid (74.3%).

Conclusions

These data indicate that trainees in US oncology programs are active participants in the prior authorization process and report that prior authorization approvals negatively influence their medical training and the quality of patient care. Additional efforts to revise the insurance approval process are warranted.