Prior authorization has been a flashpoint for providers, and, while insurers have taken steps to ease these utilization management protocols, they still play a key role as the industry shifts to value-based care.
David Brailer, M.D., executive vice president and chief health officer at the Cigna Group, told Fierce Healthcare in an interview that ultimately the goal is to ensure patients are receiving the best treatment option for them.
And the insurer has seen that in more advanced value-based arrangments, it can relax prior authorization and other utilization management tools, Brailer said.
"That's going to be a few years before the market shifts," he said. "We've already announced that we're starting to step down the number of prior auths that we have."
Brailer said that value-based care is the "capstone" of the company's specialty pharmacy arm, Accredo. As an example, its arrangement with Summa Health, an Ohio-based health system, is one of the more mature contracts, and that arrangement is designed in a way that "they do it themselves."
He said when a physician is paid in a value-based model, rather than ordering a bunch of tests or procedures to pad out reimbursement, they're focused on what matters the most for the patient's health.
"All the doctor's thinking is, 'I need to keep this patient healthy,'" he said.
However, patients who take specialty medications often have complex conditions and require intense care management. That's where utilization tools like prior authorization can prove critical in value-based arrangements that are in their infancy, or in more traditional fee-for-service relationships.
As value-based care continues to evolve, Brailer said he expects to see the industry shed the mechanisms that are built around value-based care, and this shift is good for both patients and providers.
"Because they benefit, then the patient benefits," he said. "That really comes down to when they're ready."
In the interview, Brailer also touched on recent coverage of Cigna's claims review process, which was the subject of a ProPublica deep dive. In the piece, reporters found that company records indicated that the insurer's medical directors denied claims at times in just a few seconds, much to the concern of patients and providers.
Cigna is also far from the only insurer with such protocols in place; other commercial payers as well as government insurers conduct such reviews, Brailer said.
Brailer said that about 1% of claims undergo this review, and it is typically triggered when the patient's diagnostic codes don't match the procedure; for example, ordering a vitamin D test when the patient does not have a condition that matches that.
He said those claims are sent back to the physician, who is asked to resubmit with the appropriate codes to secure payment. The medical director's name is attached to the determination to offer the submitting physician a discussion with the peer about next steps, though the reviews are largely conducted administratively.
He said that physicians will call to discuss the determinations further about 70,000 to 80,000 times per year.
"There’s a very deep belief among physicians that physicians treating patients should deal with physicians," Brailer said.