The healthcare system’s reliance on prior authorization is wasting clinicians’ time, delaying care and worsening public distrust — and yet, payers show little urgency in fixing it, according to Dr. Jesse Ehrenfeld, immediate past president of the American Medical Association.
He made this observation during an interview last week at MedCity News’ INVEST conference in Chicago.
The prior authorization process often leads to significant delays in patients getting necessary procedures, Dr. Ehrenfeld noted.
He still works as a practicing anesthesiologist in Milwaukee, and whenever he sees patients, he usually asks them how long it took to get their surgery scheduled as well as how long it took them to get their insurance company to approve it. Patients typically wait twice as long for health plan approval as they do to get their surgery scheduled, Dr. Ehrenfeld said.
“I hear about the frustration. I hear about the challenges of getting the third party payers to do what they’re supposed to do, which is to cover services. All [prior authorization] does is just add delay and confusion. We have survey data year after year after year that shows patients give up — patients don’t get what they need. It is an overused, burdensome tool that is frustrating for everybody,” he declared.
While CMS has proposed reforms that introduce service standards and transparency for plans it regulates, these changes don’t apply to the broader commercial insurance market, Dr. Ehrenfeld pointed out.
He also noted that in spite of those pending reforms, he continues to see abuses in the marketplace.
“There are dozens of companies that are building AI tools to deal with this process and to fight these denials. And we know, based on reports in the media, that third party payers are using automated tools to deny care. So we’ve got the bots beating the bots — which is not the best use of anybody’s time or effort, to build technologies that are fighting each other when we could just reform the underlying process,” Dr. Ehrenfeld remarked.
He singled out Medicare Advantage plans as having some of the worst prior authorization abuses.
Overall, Dr. Ehrenfeld views the unnecessarily burdensome prior authorization process as a huge waste of healthcare staff’s time. It consumes dozens of hours per physician per week and pulls clinical staff away from patient care, he said.
This problem is exacerbating healthcare’s workforce crisis, Dr. Ehrenfeld added. Clinicians are continuing to leave the healthcare workforce, often pushed out by excessive burnout stemming from administrative overload. There are more than 2 million clinician positions open across the country.
The U.S. is also dealing with an aging population and rising rates of chronic disease, two additional factors that increase demand on a system that is already stretched thin.
“All these administrative things just add to the burden and steal time from clinicians doing what they ought to be doing. It doesn’t make sense, and it’s not sustainable,” Dr. Ehrenfeld stated.
It’s also worth noting that this is an issue the general public is angry about.
Americans’ widespread disdain for payers and their dangerous practices was thrust into the spotlight last December after former UnitedHealthcare CEO Brian Thompson was fatally shot in New York City.
“The whole situation is horrific, and I feel awful for his family and for him, but the national response to that — the lack of empathy — was extraordinary. It’s a telling sign of a completely broken and dysfunctional system. I think Americans are good people. I meet people all the time, and there’s a lot of discord and anxiety out there, but to see that emotion come forward I think just tells you where we are,” Dr. Ehrenfeld remarked.
Still, the healthcare industry hasn’t seen commercial payers make much of an effort to address the deep public dissatisfaction with their practices — unless beefing up security for executive leaders counts as a form of accountability.
Dr. Ehrenfeld expressed some frustration with third party payers’ inaction. Despite consensus-building and public pressure, there has been little meaningful change in insurers’ practices, particularly outside CMS oversight. The AMA is urging Congress to intervene to address broader commercial plan abuses not covered by CMS reforms.
“[The AMA], in good faith, spent a ton of time over multiple years to develop a set of principles around best practices for prior authorization. There is a place for these tools — we don’t say that they should never be used, but they’re overused and they’re burdensome in the way they’re implemented. So we sat down with national medical directors from most of the major companies to develop, in a consensus format, what this should look like. Those principles are out there. They’re freely available, and then the payers completely ignored them,” Dr. Ehrenfeld stated.
To him, the rejection of those consensus-based principles signals just how little commercial insurers are willing to budge.
“It’s frustrating for us to be at the table, to try to help create consensus around how to do the right thing for Americans to elevate the health system — and then it’s just thrown out the window,” Dr. Ehrenfeld said.
Photo: Elena Lukyanova, Getty Images
