Many physicians believe prior authorization gets in the way of sound patient care. New reforms from the insurance industry aim to address these challenges. Will they make a difference?
I cover transformation and innovation across the health care industry.Many physicians believe prior authorization gets in the way of sound patient care. New reforms fromCorbis via Getty Images You learn a lot in medical school.
About human biology, medical ethics and how to make a diagnosis. One thing they don’t teach you about—but which rears its head all the time in the actual practice of medicine—is prior authorization. Prior authorization is what is known in healthcare as a utilization management tool. Physicians submit requests to insurers, who respond with determinations about whether they will cover the proposed procedures, services, or medications before the patient receives them. The goal is to steer customers toward modalities of care that have been demonstrated to produce the best outcomes at a reasonable cost. During office hours, between procedures, even in the middle of consults—prior authorization is something physicians have to deal with constantly. Last week, amid scrutiny from lawmakers and regulators as well as public outrage over the practice, health insurers working with the trade association AHIP a set of voluntary commitments aimed at simplifying prior authorization and “connecting patients more quickly to the care they need while minimizing administrative burdens on providers.” The commitments include faster turnaround times, greater transparency, and reduced requirements for routinely approved services. These reforms are sensible and—let’s be honest—probably overdue.Despite its daily impact on the practice of medicine, prior authorization isn’t something physicians talk about very much. So, in order to gauge how prior authorization affects their work and their patients and what effect the voluntary reforms might have, I reached out to several colleagues in different specialties to hear their stories about prior authorization. What I heard were honest reflections on their experience with the practice—and an urgent call to reimagine a system that too often gets in the way of care.Jay Patel, an orthopedic surgeon of the Orthopedic Specialty Institute in Orange County, CA, describes a system that increasingly delays care for no clear reason by putting up “administrative hurdles to surgeries that are appropriate.” Patel notes that some payers require that he submits imaging reports in separate documents that duplicate the information contained in previously submitted medical records. “Most of the time there’s some minor piece of information they need that’s already in the record, and they reflexively approve it.” But not always. And when delays occur, he says, they disrupt care and diminish trust between patients and their doctors. “Patients often don’t understand how the process works,” he says. “They usually think we dropped the ball because we’re the person they can get ahold of.” Patel believes the system could be improved by reducing prior authorization requirements for physicians who consistently provide appropriate care. “Good actors should be able to request surgery and have it approved.”A Northern California interventional cardiologist I know sees firsthand how delays in care can lead to worse outcomes. “For every test, you have to wait a week for authorization,” he says. “And when it comes to cardiac conditions, delays matter.” He laments that the delays can push patients to seek emergency care when they experience shortness of breath or other symptoms. “Put yourself in their shoes. When your heart hurts you may be afraid you will die.” He says that some of his patients have decided to go to the emergency room rather than wait for approvals. In these cases, the patients are admitted and treated as inpatients, which he notes is ultimately more expensive for the plan, the patient and the health system in general. The cardiologist also notes that in his field, denials are rare. Though he often has to pick up the phone to advocate for a patient, he says that in 11 years of practice, not once has a health plan denied a procedure that he’s called about. Knowing this, he wonders if artificial intelligence or other technologies could offer ways to improve the system. “There must be ways to optimize this. If they’re authorizing the procedure 99% of the time, why can’t there be instant authorization?” Internist Jonathan Dinh, CEO of Tri-Valley Medical Group/Guidant Health, says insurers often use prior authorization as a “delay tactic.” He says that in his experience, some payers intentionally make the practice burdensome, knowing that some percentage of physicians will become frustrated and give up on the time-consuming prior authorization process. “If there’s a poor clinical outcome, the health plan maintains plausible deniability. They’ll say, ‘We never said “no.” We left the decision strictly up to our providers.’” As an internist and medical group leader, Dinh believes that the efficiency of prior authorization reflects the quality of the organization itself. “In a well-run group, 80% to 90% of requests should be auto approved,” he explains. "The primary function of prior authorization should be to ensure patients are referred to the correct in-network provider, helping them avoid unnecessary medical bills—not to act as a barrier to care." Dinh says delegated models in which payors assign certain administrative and clinical responsibilities—like utilization management, care coordination, and prior authorization decisions—to a provider organization or medical group can reduce the friction of prior authorization. However, he cautions that this model alone isn’t enough. "Delegated entities can still improperly delay or deny care. There must be safeguards—such as expedited appeal processes—to protect patients.” Dinh also says that patients often mistakenly blame delays in seeing a specialist due to the prior authorization process when the real underlying issue is a shortage of physicians. "People often blame delays in seeing a specialist on the prior authorization process,” he says. “But in many cases, referrals are issued promptly—the real bottleneck is a shortage of physicians. Specialists are overwhelmed and simply don’t have the capacity to see patients quickly. Of course, any delay in prior authorization only makes the situation worse.”internal medicine residency program focusing on training more primary care internists. The initiative aims to expand access to care and improve outcomes, particularly in underserved communities. “A well-trained internist can help offset the shortage of specialists by managing complex conditions at a high level. The true value of a primary care physician emerges when a patient’s care requires coordination across multiple specialties. The ability to lead multidisciplinary care while keeping the patient and their family informed is what ultimately drives the best clinical outcomes and enhances patient satisfaction.”When a draft of AHIP’s plan initially crossed my desk, I was skeptical. Voluntary reform isn’t something that necessarily has a great track record in healthcare. And yet more than) that provide coverage to tens of millions of Americans have signed on and made a public commitment to reform. After speaking to my physician colleagues and hearing their earnest frustrations, there’s no doubt in my mind that the system needs reform and the association’s proposals—which are not insubstantial and would address many of the problems —are a great place to start. After all, none of the physicians I spoke to are asking for a blank check. They’re asking for a system that trusts their judgment, respects their time, and puts patients first. Reforming prior authorization isn’t just about efficiency. It’s about dignity—restoring it to the people who give care, and the people who need it—and AHIP’s plan, acknowledging some of the challenges my physician colleagues face every day, is a meaningful step in the right direction.
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