ACR: Prior Authorization Requirements Must Be Reduced

Prior authorization (PA) for rheumatology drugs, many of which are biologics or biosimilars, needs to be improved as it can cause delays in care and is burdensome for providers and patients, the American College of Rheumatology (ACR) said in an official position statement.

“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,” said Virginia Reddy, MD, lead author of the statement and a member of the ACR’s Committee on Rheumatologic Care.

"In addition to creating additional hoops for patients and providers to jump through, prior authorization diverts valuable time away from caring for patients and toward repetitive and time-consuming administrative tasks,” she added.

Although payers require PA for the purposes of oversight and control over providers’ prescribing practices, the ACR said this process is often time-consuming and diverts resources away from direct patient care.

The ACR’s patient registry data found that approximately 15% of patients in a typical rheumatology practice have rheumatoid arthritis and are treated with a medication that requires PA. For each of these patients, clinicians must go through the PA process at least once per year due to annual therapy renewal requirements for insurance plans.

The ACR said PA requirements are not standardized across payers, and providers frequently must fill out multi-page forms manually for each patient, which affects timely treatment of patients.

The ACR’s 5 main recommendations to modernize and simplify the PA process:

• Reduce the number of rheumatologists and rheumatology professionals subject to PA by not requiring PAs if clinicians are already meeting performance measures, following evidence-based practices, or participating in value-based agreements with payers.
• Reduce the number of services and medications that require PA by regularly reviewing and removing unnecessary requirements.
• Improve transparency and channels of communication between payers, patients, and clinicians; minimize delays in care; and ensure PA requests are reviewed by qualified personnel with specialty-specific credentials who will provide reasons for denials in a timely and understandable manner.
• Protect continuity of care when changes occur in coverage, payers, or PA requirements to ensure there is no interruption of care for patients.
• Accelerate industry adoption of national electronic standards for PA and improve transparency around formulary decisions and coverage restrictions.

"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," Reddy said.

In a national survey conducted by the American Medical Association, 75% of physicians reported that PA can lead to patients abandoning therapies. Additionally, 91% of physicians indicated they believe that the PA process delayed patients’ access to care, and 88% of physicians reported that the burden associated with PA has increased in the last 5 years.

Current legislation aimed at minimizing PA issues for patients includes the Improving Seniors’ Timely Access to Care Act, or HR 3107. The bipartisan bill would require CMS to regulate PA use by Medicare Advantage plans and establish a process to make “real-time decisions” for services that are routinely approved.

It also would require plans to offer a process for electronic PA and to report to CMS how much they use, approve, and deny PA.

The ACR is an international society with a membership of over 8500 rheumatologists and rheumatology professionals.