Seniors deserve timely access to care, not bureaucratic hurdles | Viewpoint

Like most doctors, I’m awed by the transformative power of medicine in my patients’ lives. Yet, I’m also frustrated that insurers are increasingly delaying or denying necessary care.

Jane C. Edmond, MD

That’s because doctors’ ability to provide procedures and medications is hampered by the bureaucratic nightmare that is prior authorization built into many Medicare Advantage plans.

Prior authorization, which requires doctors to jump through numerous administrative hoops before insurance companies approve necessary treatments, impacts every specialty in medicine. According to the latest data from the American Medical Association, 94% of physicians say prior authorization delays patients’ access to necessary care, 78% report prior authorization causes patients to abandon their treatments, and 24% say prior authorization has led to a serious adverse event for a patient in their care.

But what’s worse is that many of these adverse events could have been prevented entirely. In 2022, MA plans denied roughly 7.4% of the 46 million prior authorization requests submitted. Though only one-in-ten of these denials were appealed, a whopping 83% of the appeals led to insurers’ decisions being overturned, suggesting patient care was unnecessarily delayed.

What can go wrong with the prior authorization process? Consider the case of one patient whose routine cataract surgery was denied by her Medicare Advantage plan.

For many seniors, getting cataract surgery can mean the difference between living independently and relying on others for help with daily tasks like driving, cooking, or walking. Peggy Mitchell, a Medicare Advantage beneficiary from Alpharetta, was forced to delay her right eye cataract surgery when her insurer denied approval for this routine surgery––even though she had successfully had a cataract removed from her left eye only a year before.

After a long appeal process, the denial was eventually overturned, but not before her MA plan’s policy had already caused tens of thousands of other cataract surgeries to be canceled. While her insurer eventually rescinded its sweeping prior authorization policy for cataract surgery in all states except Florida, there is still a glaring problem with MA insurance obstacles.

In fact, many other insurers erect similar barriers that prevent patients from getting the cancer, rheumatology, substance use disorder, and other care they desperately need. As a result, the Kaiser Family Foundation estimates 99% of MA beneficiaries are forced to get prior authorization for some services.

The administrative burden of prior authorization doesn't just impact patients; it also strains our healthcare system. All the time spent battling insurance companies is time taken away from patient care. Doctors and their staff are forced to dedicate valuable resources to navigate the labyrinth of an approval process, diverting them from their core responsibility – providing quality care.

This costs practices money that they would much rather invest in direct patient care and forces them to hire staff solely dedicated to managing the overwhelming amount of paperwork insurers require. It's unacceptable that insurers are requiring physicians to complete unnecessary, extensive, burdensome paperwork that insurers then use to overrule physicians’ clinical judgment and trusted relationships with patients.

Ultimately, when coverage for medically necessary care is denied, patients are forced to forgo care altogether or pay for treatments out of their own pockets, often at great expense. In fact, four-in-five doctors (79%) say that delays and denials caused by prior authorization force patients to pay out-of-pocket for medications at least part of the time.

And now, with the rise of AI, I’m even more concerned as Medicare Advantage plans are using AI-powered decision-making tools to make coverage decisions that may be more restrictive than Medicare coverage guidelines.

Americans have had enough. It’s time we address this rampant problem.

With time running out in the 118th Congress, I urge lawmakers to quickly pass The Improving Seniors’ Timely Access to Care Act. This widely supported, bipartisan legislation would put guardrails around the prior authorization process in MA plans by:

• Establishing an electronic system: Eliminating the antiquated fax system and mandating electronic submission of documents would streamline the process and reduce errors that delay care.
• Increasing transparency: There is currently a lack of available data about MA claim denials. This bill would require plans to submit more detailed data to give patients and providers more transparency throughout the entire process.
• Speeding up decisions: By clarifying the Center for Medicare & Medicaid Services’ authority to establish timeframes for e-prior authorization requests, patients enrolled in MA plans will be able to get the care they need quicker.

The Improving Seniors’ Timely Access to Care Act recently reached a major milestone: It now has 50 cosponsors in the Senate and more than 218 in the House of Representatives. Everyone knows modernization of the prior authorization process is long overdue. That’s why lawmakers on both sides of the aisle and hundreds of healthcare organizations are all in agreement.

It's time for Congress to finish the job. Pass this prior authorization bill before the end of the year.

Jane C. Edmond, MD is the president of the American Academy of Ophthalmology.