News Release 

ACR releases position statement on prior authorization

American College of Rheumatology

ATLANTA - The American College of Rheumatology (ACR) has released an official position statement concerning prior authorization for the approval of prescription medications, highlighting the significant burdens 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.

"In addition to creating additional hoops for patients and providers to jump through, prior authorization 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 (CORC). "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 prior authorization process with these five key areas of improvement to ensure access to care for patients:

  • Reduce the number of rheumatologists and rheumatology professionals subject to prior authorization requirements by not requiring prior authorizations 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 prior authorization 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 prior authorization 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 prior authorization and improve transparency around formulary decisions and coverage restrictions at the point of care.

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

A national survey of over 1,000 practicing physicians conducted by the American Medical Association (AMA) found that 75 percent of physicians reported that prior authorization can lead to patients abandoning recommended therapy and 91 percent believed that the prior authorization process delayed patients' access to care. Further, the AMA survey revealed that 88 percent of physicians reported that the burden associated with prior authorization has increased in the last five years.

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

"It is crucial that these improvements be made with careful, deliberate attention to each targeted area so that patients can receive the treatment they need without unnecessary delays," Dr. Reddy added. "And in order to fully address the problems associated with prior authorization while minimizing the risk of unintended consequences, future reforms should include all of the ACR's targeted areas of improvement."

Efforts to improve some elements of prior authorization are already underway in Congress. The ACR supports the Improving Seniors' Timely Access to Care Act (H.R. 3107), a bipartisan bill sponsored by Reps. Suzan DelBene (D-WA), Ami Bera (D-CA), Mike Kelly (R-PA) and Roger Marshall (R-KS), which would require the Centers for Medicare and Medicaid Services (CMS) to regulate the use of prior authorization 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 prior authorization and to report to CMS how extensively they use prior authorization and how often they approve or deny the relevant medications and services.

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The American College of Rheumatology (ACR) is an international medical society representing over 8,500 rheumatologists and rheumatology health professionals with a mission to empower rheumatology professionals to excel in their specialty. In doing so, the ACR offers education, research, advocacy and practice management support to help its members continue their innovative work and provide quality patient care. Rheumatologists are experts in the diagnosis, management and treatment of more than 100 different types of arthritis and rheumatic diseases. For more information, visit http://www.rheumatology.org.

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