A group of 17 healthcare industry stakeholders has published a set of guidelines to improve payer prior authorization programs in an effort to improve timely patient treatment access.
Treatment authorization programs, known as utilization management programs, are the processes payers use to approve treatments such as pharmaceuticals, durable medical equipment, and medical devices.
These programs include prior authorization processes, during which payers determine if they will reimburse providers for a certain treatment before it can be administered. They also include step therapy, during which patients and providers exhaust less expensive treatment options before accessing more intensive therapies.
Payers argue that these processes are necessary for cost containment.
However, as the healthcare industry continues to put patient needs at the forefront of care, the stakeholders, led by the American Medical Association, contend that prior authorization is burdensome and hinders timely access to treatment.
“Utilization management programs, such as prior authorization and step therapy, can create significant barriers for patients by delaying the start or continuation of necessary treatment and negatively affecting patient health outcomes,” the group said.
These programs are notoriously inefficient, they continued, and lack the transparency necessary for patients and providers to move through the process swiftly.
“Due to its widespread usage and the significant administrative and clinical concerns it can present, the AMA believes that prior authorization is a challenge that needs to be addressed through a multifaceted approach to reduce burdens on physicians and patients,” the organization said.
The AMA, alongside other industry leaders such as the American Academy of Family Physicians, the American Hospital Association, and the Medical Group Management Association, put forth suggestions to make prior authorization a timelier and fair process that accounts for continuity of patient care rooted in clinical validity.
Timely access and reducing administrative burden
Payers need to ensure that prior authorization and other utilization management requests are handled quickly, the group said.
“In order to ensure that patients have prompt access to care, utilization review entities need to make coverage determinations in a timely manner,” the organizations said. “Lengthy processing times for prior authorizations can delay necessary treatment, potentially creating pain and/or medical complications for patients.”
In the case that a payer denies a prior authorization, the AMA said they must act to quickly conduct an appeals process should a patient request one.
Additionally, prior authorization should never be required for emergency care to ensure patients can access any treatment they urgently need.
Timely utilization management programs also require administrative efficiency, the groups explained. Payers can reduce administrative burden by using appropriate electronic transfers to conduct prior authorization reviews. Different industry payers should also work to create a standard set of requirements for utilization management programs.
If payers work to reduce administrative burden, providers will be able to submit required prior authorization materials more quickly and ultimately deliver treatment to patients faster.
Fostering process transparency, fairness
Patients and providers who do not know what treatments they can and cannot access also face considerable barriers to patient care access, the AMA said.
In order for patients and their care teams to make truly informed decisions, payers need to be transparent about which treatments are automatically included in a health insurance plan and the review process for ones that require prior authorization.
Additionally, payers need to offer adequate information when rejecting a prior authorization request to allow care teams to more easily alter their treatment course.
“In order to promote provider (physician practice, hospital and pharmacy) and patient understanding and ensure appropriate clinical decision-making, it is important that utilization review entities provide specific justification for prior authorization and step therapy override denials, indicate any covered alternative treatment and detail any available appeal options,” the AMA said.
Ensuring continuity of patient care
Utilization management may not only delay patient care, the AMA said, but also interrupt ongoing treatment. Especially when patients change payers, continuity of care due to prior authorization requirements becomes a significant access burden.
According to the AMA, payers should ensure patients can continue treatments while undergoing review processes.
“In the event that, at the time of plan enrollment, a patient’s condition is stabilized on a particular treatment that is subject to prior authorization or step therapy protocols, a utilization review entity should permit ongoing care to continue while any prior authorization approvals are obtained,” the AMA said.
Additionally, patients should not be required to undergo repeated step therapy when changing health plans.
Should a health plan remove a certain treatment from a plan formulary – a set of pre-approved treatments that are a part of a health plan – they should allow the patient to continue the regimen until the start of a new plan year.
Rooting decisions in clinical validity
Ultimately, providers determine treatment options for the benefit of their patients. While cost containment is an important healthcare goal, the AMA says prior authorization decisions must always be based on clinical evidence and not just treatment cost.
Payers should also be flexible in coverage decisions, the organization wrote, because treatments are based on patient and provider needs.
“The most appropriate course of treatment for a given medical condition depends on the patient’s unique clinical situation and the care plan developed by the provider in consultation with his/her patient,” the stakeholder groups noted.
“While a particular drug or therapy might generally be considered appropriate for a condition, the presence of comorbidities or patient intolerances, for example, may necessitate an alternative treatment.”
At the helm of these coverage decisions should be a clinical expert because prior authorization decisions require extensive knowledge about disease management and treatment, the AMA said.
“As this essentially equates to the practice of medicine by the utilization review entity, it is imperative that these clinical decisions are made by providers who are at least as qualified as the prescribing/ordering provider,” the organizations wrote.
The AMA’s bottom line is improved patient access to care. As the healthcare industry continues to embrace patient-centered care, patients and providers are increasingly working together to make informed healthcare decisions.
From there, the onus is on the payer to approve reimbursement for treatments, making them available for patients in a fair and timely manner.