AI-Driven Prior Authorization Denials Jeopardize Patient Care, AMA Survey Reveals
A recent survey by the American Medical Association (AMA) has highlighted growing concerns among physicians regarding AI Prior Authorization used by health insurers. According to the 2024 AMA prior authorization physician survey, 61% of doctors are worried about the increasing reliance on unregulated AI systems for making authorization decisions. These AI-driven processes, often with little to no human oversight, are significantly raising denial rates for essential medical treatments, worsening patient harm, and adding inefficiencies to the healthcare system.
Prior authorization, a process requiring healthcare providers to obtain approval from insurers before administering specific treatments or medications, has long been criticized for creating barriers to timely patient care. The integration of AI into this process was initially intended to streamline operations and reduce administrative burdens. However, the AMA’s findings suggest that the unregulated deployment of AI has intensified existing challenges, leading to adverse patient outcomes and increased physician burnout.
Key Findings from the AMA Survey:
Patient Harm: Over 29% of physicians reported that prior authorization requirements have resulted in serious adverse events for patients, including hospitalization, permanent impairment, or even death.
Delayed Care: A significant 93% of respondents indicated that prior authorization processes delay access to essential treatments, potentially worsening patient conditions.
Negative Clinical Outcomes: Approximately 94% of physicians observed that prior authorization negatively impacts patient clinical outcomes, undermining the quality of care provided.
Treatment Abandonment and Financial Strain: About 82% of physicians noted that patients abandon recommended treatments due to authorization challenges, and 80% reported that patients are compelled to pay out-of-pocket for services not covered promptly, leading to financial hardships.
Physician Burnout: Nearly 89% of physicians stated that the demands of prior authorization contribute significantly to professional burnout. On average, physicians handle 39 prior authorizations weekly, consuming approximately 13 hours of physician and staff time.
The survey also highlights a troubling trend: 75% of physicians have experienced an increase in prior authorization denials over the past five years. This surge persists despite reform agreements established in 2018 among key stakeholders aimed at addressing prior authorization challenges. The introduction of AI, intended to enhance efficiency, appears to have compounded these issues.
Dr. Bruce A. Scott, AMA President, emphasized the gravity of the situation in a recent press release: “Utilizing AI-enabled tools to automatically deny more and more needed care is not the reform of prior authorization that physicians and patients are calling for. Emerging evidence shows that insurers use automated decision-making systems to create systematic batch denials with little or no human review, placing barriers between patients and necessary medical care. Medical decisions must be made by physicians and their patients without interference from unregulated and unsupervised AI technology.”
The report further notes that while insurers such as UnitedHealthcare and Cigna announced reductions in the number of services requiring prior authorization in 2023, only 16% of physicians working with these payers have observed any decrease in their administrative workload. Notably, UnitedHealthcare received a “high” or “extremely high” burden rating from 72% of physicians, indicating that announced policy changes have not translated into tangible improvements in clinical practice.
The AMA’s findings arrive at a critical juncture as the healthcare industry increasingly integrates AI technologies into various operational facets. While AI holds promise for enhancing efficiency and reducing costs, its application in prior authorization processes raises ethical and practical concerns, particularly when it leads to the denial of necessary patient care.
The AMA advocates for a paradigm shift toward “augmented intelligence,” wherein AI serves to support and enhance human decision-making rather than replace it. This approach emphasizes the importance of human oversight in medical decisions, ensuring that patient care remains personalized and contextually appropriate.
The implications of the survey are far-reaching, suggesting that without proper regulation and oversight, AI-driven prior authorization systems may undermine patient safety and the overall efficacy of healthcare delivery. The AMA calls for immediate action to address these challenges, urging policymakers, insurers, and healthcare providers to collaborate in developing frameworks that ensure AI technologies are used responsibly and effectively in patient care processes.
In conclusion, while AI has the potential to revolutionize aspects of healthcare, its current application in prior authorization requires careful scrutiny and regulation. Ensuring that medical decisions are guided by clinical expertise and patient-specific considerations is paramount to maintaining the integrity and quality of healthcare services.
