The requirement that physicians get prior authorization from insurers before providing a medical service, diagnostic test or medication may be the greatest single bottleneck for the delivery of quality healthcare.
Consider, for example, that the majority of authorizations still happen via manual submission of the request and supporting clinical documentation via fax or phone. Or that rather than getting approval for all that would be needed for a knee replacement—the device, pre-op and post-op visits, crutches, pain medication and physical therapy— in one bundle, in many cases approvals need to be sought for each individual item or service.
No doubt, there are legitimate concerns about ensuring that physicians are recommending necessary and cost-effective treatments for patients.
But the time it takes to explain the recommendations to insurance administrators and share supporting documentation is extensive and excessive. In a recent Medical Group Management Association survey on administrative burdens faced by medical groups, prior authorization was listed as their No. 1 complaint, which they argue has a devastating impact on delivery of timely, quality care for patients.
The truth is, it doesn’t have to be this way. Most credible estimates suggest that as many as 90% of the prior approvals sought from insurers are ultimately OKed, but not without the burden of submitting mountains of paperwork and explanations.
Solving the prior approval conundrum would dramatically affect the delivery of medical care, allow practices to be more efficient and improve patient outcomes.
When you think about the problem, you might ask, who is in the best position to determine patient care? An administrator at a health insurance company or the physician in the room with a patient?
The answer is obvious.
At a time when, according to a recent study published in JAMA, administrative complexity can cost our healthcare system some $266 billion per year, we need to do better.
Adopting the following five simple steps now would dramatically address the prior authorization challenge:
1. Gold card system: Physicians who have consistently demonstrated adherence to insurer’s requirements for prescribing medications and medical procedures should not have to get prior approvals.
Each insurer would likely keep different standards for gold-carding physicians, so an industry standard would be an optimal solution. Remember, physicians report spending close 15 hours per week on prior authorization requirements, so even cutting this number in half would free up considerable time that could be better spent on delivering care to patients.
2. Automation: Use of clinical decision support automation tools can reduce the need for prior authorization by identifying the appropriate treatment or medication based on established clinical guidelines. If, for example, a physician wanted to order an MRI for a specific condition, the software would advise in real time if it was warranted based on data gathered from a broad collection of clinical experts and outcomes.
Further, the multi-stakeholder group CAQH reports that while almost 100% of claims are submitted electronically to payers, just 12% of prior authorization requests are sent electronically. Expanded use of this transaction, coupled with release of the long delayed electronic attachment standard, would eliminate much manual work and drive out costs for both practices and payers.
Looking ahead, innovations such as the Da Vinci project, which seeks to set standards to smooth communication between payers and providers, offer the promise of increased automation.
3. Improved transparency: Improving the communication between payers and providers regarding what medical services and prescription drugs require prior authorization and what documentation is necessary to support a request would go a long way toward easing burdens.
This information should be easily accessible on payer websites with any policy changes transmitted to providers on a regular basis via payer bulletins. As a step in the right direction, the Centers for Medicare & Medicaid Services has launched an initiative that will permit the physician to communicate directly with the payer system via their electronic health record system to determine whether a prior authorization is needed and what supporting documentation is required.
4. Continuity of patient care: So often, when a patient changes to a different health insurance carrier, the new insurer requires a repeat of protocols for treatment under the guise of controlling costs. This can lead to a deterioration in the patient’s condition and additional burden for the treating physician.
Establishing an approach of accepting the previous insurers authorization would avoid a disruption to a patient’s current course of treatment and avoid a potentially costly worsening of the condition. Solving this challenge appears simple but has proven to be agonizingly difficult.
5. Speedy approvals: The current manual process of conducting prior authorizations slows down patient care. In an American Medical Association study, nearly two-thirds of physicians reported a delay of at least one business day for prior authorization decisions from insurers, while more than a quarter have waited three business days or longer.
Most concerning, three-quarters of physicians report that this delay can sometimes lead to patients abandoning a recommended course of treatment. Establishing automated processes that result in faster approvals is imperative if we are to appropriately treat patients and ensure that treatments are not abandoned.
Although the industry is currently seeking to establish maximum response times for payers to respond to an electronic authorization request, getting payers to agree to shortened times has proved challenging.
A lot of thought has gone into tackling the prior authorization problem, but taking these five steps hold much promise for enhancing patient care and decreasing the associated administrative burdens. Solving this problem now is in everyone’s best interest.
Robert Tennant is the director of health information technology policy in the Medical Group Management Association’s Washington, D.C., office.