The Prior Authorization Burden: States are Forging Ahead with Legislation to Lighten the Load

June 14, 2023

By Casey Korba, Director of Policy

Prior authorization (PA) was developed as a tool to help curb waste and overspending. However, we consistently hear from Aledade primary care clinicians that burdensome requirements negatively affect clinicians’ ability to offer timely and appropriate treatment to their patients. On May 24, Aledade’s State Policy Team hosted its second Multi-state Policy Collaborative webinar, Lightening the Load of Prior Authorizations in Primary Care to further explore the topic. 

Dr. Becky Jaffe, Senior Medical Director at Aledade, facilitated a lively and informative discussion with subject matter experts. The speakers included Senator Missy Irvin (R-AR), who helped pass legislation to streamline prior authorization in Arkansas, in addition to Dr. James Zini (AR) and Dr. John Cawley (CO), who provided physician perspectives from their respective states. Ryan Biehle, CEO and EVP of the Colorado Academy of Family Physicians, also discussed legislative advocacy efforts underway in Colorado.

Legislative strategies include increasing transparency and rewarding clinicians 

Senator Irvin shared that she began advancing legislation to address prior authorization in Arkansas in 2011. At that time, many stakeholders told her it would never happen. Her advice to the audience was, “Do not give up. Harness the power of your constituents….and bring their stories to your state’s capitol.” She also noted the importance of having legislators listen to family practice physicians share their insights into the hours and resources spent on prior authorizations. Arkansas had previously passed legislation increasing transparency from health plans, and in 2023, Senator Irvin and others amended the bill to create exemptions for clinicians with a history of >90% prior authorization approvals on requests for a particular service. 

Ryan Biehle discussed Colorado’s ongoing journey to pass legislation. The Colorado Medical Society brought a bill forward in the 2023 session that had some early successes but ran into roadblocks related to short-term costs. Biehle noted efforts underway to shore up support for a comprehensive bill that includes medical services and prescription drugs in 2024. Despite the challenges, a growing coalition of patient advocates, pharmacists and other clinician stakeholders have elevated the prior authorization burden as a patient care issue, physician burden and a workforce barrier. Looking forward, Biehle “is excited to move forward and persist,” inspired by Senator Irvin’s success. 

The physician perspective: prior authorization burdens disrupt the patient relationship and care

Dr. Cawley, who ran a practice in Fort Collins, CO for many years and is now a Regional Medical Director at Aledade, spoke about a young patient in good health who came to him after being assaulted by a former partner living with HIV. He was scared and frantic, and Dr. Cawley knew they had about 72 hours from the time of exposure to get the post-exposure prophylaxis. Dr. Cawley soon learned the patient would need to pay $18,000 for the three medications–money that the patient didn’t have. His practice urgently put in an emergency prior authorization request to the health plan and explored potential patient assistance programs. 

Having been in value-based care for a while, Dr. Cawley was able to take advantage of some shortcuts, including easier access to a pharmacist. But even with discounts, they were only able to get the price down to $10,000, which was still not feasible for the patient. It took a month for the health plan to fax the approval for the medications. As a result, the team was forced to move on to establishing testing regimens and a plan for early treatment. Dr. Cawley lamented,

“This is an area where we have great technology and medications that could intervene to decrease the risk of contracting HIV, but a prior authorization got in the way of good care and potentially increased the total cost of care.”

Dr. Zini runs the Zini Medical Clinic in Mountain View, AR. He shared a story of a patient with a history of kidney stones who came to his clinic in pain. After a workup, Dr. Zini felt confident the patient was experiencing kidney stones, but the patient’s health plan required imaging before he could proceed with treatment. The prior authorization process took three additional days. Dr. Zini noted that he could have sent the patient to the emergency room (ER) to get the imaging without prior authorization, which would have cost the patient and the health care system exponentially. Instead, Dr. Zini chose to manage the patient’s pain.

Solutions to reduce prior authorization burdens

Aledade is calling for the following solutions:

  • Invest in independent primary care and accountable care models to ensure the long-term sustainability of practices that provide high-quality care without depending on volume.  
  • Streamline requirements through gold card programs including exemptions for clinicians in accountable care and risk-based contracts. 
  • Authorize waiving PA for a minimum period for certain services to avoid unnecessary duplicative requests; for those with chronic conditions, the PA should be valid for the length of treatment.
  • Improve transparency on PA request data, require data reporting on requests and continue to develop technology to improve efficiency.

Senator Irvin and Mr. Biehle emphasized that prior authorization burdens can be a weedy, complex issue for legislators to understand. Bringing in a diverse group of stakeholders, including health plans to build common ground with clinicians on workable solutions is critical. Dr. Zini noted the importance of gathering data when possible–running the numbers on the return on investment for getting a patient more timely treatment vs. sending that patient to the ER, for example. 

Interested in what’s coming next? Aledade will continue to work with our physician-led state policy committees to advance common sense legislation to reduce prior authorization burden for primary care clinicians participating in advanced alternative payment and accountable care models. For more information, read our recent briefAddressing the Burden of Prior Authorization Requirements in Independent Primary Care.