Earlier this year, we invited primary care physicians, including pediatricians, to join us for dinner and discussion. We wanted to know why New Jersey physicians have low participation rates in both Medicaid and Medicare.

We expected to hear a great deal about low reimbursement rates. Instead, we heard about the daily frustrations of physicians. They feel continually second guessed by insurers —especially when it comes to prior authorization. Even physicians willing to jump through the necessary hoops complain the hoops keep moving. And these hoops, they say, add little value while taking the joy out of practicing medicine.

The physicians cited one particularly painful area — approvals for medication, one of the top three areas of Utilization Management appeals in New Jersey. With so many health plans and pharmacy benefit managers, each with different formularies and tiers for prescription drugs, doctors find it challenging to focus on what’s best for their patients. And often the preferred drug lists change during the year, further adding to the administrative burden to both doctor and patient.

One doctor, trying to order buprenorphine to help a patient addicted to opioids, told us he was on the phone battling an insurance company for the entire drive from his office in Monmouth County to Atlantic City, which is over 85 miles and rounds out to about 90 minutes.

Despite technological advances, not enough insurers make the authorization process simple and doctors complain about the amount of time they and their staff spend on the tedious process. And what really irks providers, and patients, is that after lengthy processes, few requests are denied. And many of the denials are overturned on appeal.


Shouldn’t there be a better way to strategically design a prior authorization process?


At the Quality Institute, we think the answer is yes. That’s why we’re calling for a reevaluation of the state’s laws and regulations around utilization management and prior authorization. There hasn’t been a comprehensive review of these areas in about a decade. Much has changed in health care since then. Other groups, such as the Medical Society of New Jersey, also are calling for revisions. You can read the society’s recent report here. This calls for fewer drugs and procedures to be subject to prior authorization and greater automation and transparency.

Meanwhile, a coalition of organizations, including the American Hospital Association, America’s Health Insurance Plans, and the American Medical Association, created a consensus statement that calls for improving the prior authorization process. One recommendation calls for adjustments when providers participate in risk-based payment contracts. We heard similar sentiment at our Quality Breakfast with Catalyst for Payment Reform, a non-profit organization that helps employers and payers get better value for their health care dollars. Clinicians on our panel said they believe providers would be more willing to accept financial risk if the administrative burden of prior authorizations was eased. So, revamping prior authorization could further payment reform.

I’m not ready to toss out prior authorization altogether. We know unnecessary care drives up health care costs and even harms patients. But we also need to recognize that senseless barriers to care contribute to physician burnout, so we need to take the needs of patients and physicians seriously.

At the Quality Institute, we have a history of successfully convening work groups on many complex issues and we stand ready to help here, too. We can provide a supportive or leadership role and bring together providers, insurers, legislators, and state leaders to the table to listen to each other and craft solutions. I am eager for your thoughts and encourage you to reach out.