Prior Authorization for Psychopharmacology

Approved by Council May 2019

Background

Child and adolescent psychiatrists strive to provide effective and safe treatment to children, incorporating evidence-based practices and patient-centered care, while recognizing the need to reduce costs associated with care delivery.

Current prior authorization procedures require time and effort by child psychiatrists, an undersupplied specialty needed for safe prescribing of psychotropic medication to children with psychiatric disorders.  This process often takes significant time away from direct patient care. A 2017 American Medical Association (AMA) survey found that the average physician spends 14.6 hours per week processing prior authorizations.1

Administrative burdens associated with prior authorization processes can interfere with the ability of child and adolescent psychiatrists to treat patients of high complexity. Prior authorization procedures may result in determinations that restrict a child’s access to clinically necessary treatment. According to AMA’s survey, 78% of physicians reported that patients abandon treatments when waiting for prior authorizations to be completed. These factors degrade the quality and increase the overall cost of care. Undertreated psychiatric disorders in children increase medical costs for children and for their parents.

The American Academy of Child & Adolescent Psychiatry has joined numerous medical organizations and insurers in endorsing “Prior Authorization and Utilization Management Reform Principles” posted on AMA’s website.2 The 21 principles listed represent our concerns. The following recommendations are focused on the specialized needs of children and adolescents and support care delivery by child and adolescent psychiatrists.

Recommendations

The American Academy of Child and Adolescent Psychiatry recommends:

  • Child and adolescent psychiatrists be included on formulary committees, drug utilization review boards, payer Quality Improvement (QI) committees, and be designated as prior authorization reviewers. Child and adolescent psychiatrists have specific knowledge that will be beneficial to this process.
  • Prior authorization processes and review procedures should be streamlined and standardized across care delivery systems.
  • E-prescribing and other medication management systems should include rapid identification of current formulary medications and alternatives through such means as prior authorization portals and digital updates to electronic medical records and e-prescribing systems.
  • Following any initial denial, the option of direct and expedited access to discussion with a child and adolescent psychiatrist with the authority to override the denial should be provided.
  • In keeping with the AMA “Prior Authorization and Utilization Management Reform Principles” all appeals decisions should be made by child and adolescent psychiatrists

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The American Academy of Child and Adolescent Psychiatry promotes the healthy development of children, adolescents, and families through advocacy, education, and research. Child and adolescent psychiatrists are the leading physician authority on children’s mental health.