- A group of healthcare industry leadership groups have banded together to improve the prior authorization process, in turn supporting streamlined patient access to treatment.
The coalition – which includes the likes of the AMA, AHA, America’s Health Insurance Plans (AHIP), Medical Group Management Association (MGMA), the American Pharmacists Association (APhA), and Blue Cross Blue Shield Association – aims to reduce the barriers patients face in healthcare access.
Prior authorization is the process by which a healthcare payer approves a treatment for a certain patient. Patients and their providers must submit certain materials to healthcare payers, which the payer in turn uses to make its decision.
Industry leaders have been critical of prior authorization rules, stating that these rules prevent patients from receiving treatment in a timely manner. When a patient is facing a life-threatening illness such as cancer, time is important.
Prior authorization protocol are currently insufficient because they are not streamlined, hindering patients, providers, and healthcare payers.
“The prior authorization process can be burdensome for all involved—health care providers, health plans, and patients,” the industry groups wrote in their consensus statement.
“Yet, there is wide variation in medical practice and adherence to evidence-based treatment,” they continued. “Communication and collaboration can improve stakeholder understanding of the functions and challenges associated with prior authorization and lead to opportunities to improve the process, promote quality and affordable health care, and reduce unnecessary burdens.”
The groups listed five key strategies for improving the prior authorization process and allowing patients timely access to their treatments.
First, the group said fewer providers should be subject to the prior authorization process. Provider exclusion from this process should be based off performance, adherence to evidence-based protocols, and value-based care agreements between the provider and a healthcare payer.
Second, industry stakeholders should regularly review the treatments included on prior authorization lists. Some treatments may no longer warrant prior authorization and should be removed from these lists.
Next, industry groups should work to build better communication between patients, providers, and healthcare payers during the prior authorization process. This will make the process clearer, streamlined, and more efficient. Ultimately, this will help patients access treatments more expediently.
Fourth, the coalition asserted that organizations must preserve continuity of care for patients who have already completed prior authorization for a certain treatment. Often, chronically ill patients who change insurers need to undergo prior authorization again, barring access to a treatment they were already using. Prior authorization must be reciprocal to halt this issue.
Finally, the healthcare industry must adopt standards for electronic prior authorization. Digitizing the process will allow patients to access treatments quicker and more seamlessly.
These groups have been dedicated to streamlining prior authorization for some time. The AMA, for example, led 17 industry groups in publishing prior authorization guidelines in 2016.
“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 in the guideline.
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.
Since then, other healthcare professionals have jumped on the bandwagon. Maryland introduced legislation prohibiting insurers from presenting unreasonable care barriers in 2017. That legislation barred exorbitant prior authorization measures.
Overcoming these barriers have become a national imperative for industry leaders. A 2017 report from the American Society of Clinical Oncology found that utilization management strategies such as prior authorization keep cancer patients from accessing their treatments.
And a more recent report from the Doctor-Patient Rights Partnership (DPRP) found that drug formulary exclusion lists are getting longer. Drug formulary exclusion lists include drugs, therapies, and treatments that a healthcare payer does not cover.
Drug formulary exclusion lists from two large pharmacy providers have increased by 160 percent since 2014, the DPRP report found, hindering patient access to care.
Proponents of drug formulary exclusion lists and prior authorization rules state that these strategies reign in extraordinary healthcare costs by ensuring patients use the most effective drug for the lowest possible price.
To their credit, many of those supporters are correct. CVS Caremark predicts it will save $4 million from its drug formulary exclusion list and Express Scripts reported it will save about $2.5 million, according to the DPRP report.
But with the care barriers many patients currently face, healthcare professionals must reshape these systems, critics counter. Healthcare payers and other financial stakeholders can determine effective cost-cutting strategies that also allow better patient access to treatment.