- HHS is looking for ways electronic prior authorization can be improved, Office of the National Coordinator for Health IT head Don Rucker said Monday at Academy Health's annual research conference in Washington, D.C.
- Rucker, who has helmed ONC for the past two years, lambasted the current state of prior authorization, the requirement that providers obtain approval from a patient's insurance before prescribing medication or therapy, calling it a "non-computerized kabuki of payment" that "needs to get rethought."
- ONC's goal is to reintegrate financial, clinical and quality data within health IT transactions, Rucker said. "Prior auth may be the battlefield to do that."
Provider groups have been arguing against prior authorization for years, arguing it adds administrative burden to their workflow and can harm quality of care or stop patients from receiving life-saving medical treatments. According to the American Medical Association, 28% of providers reported PA affected care delivery and led to a serious adverse event.
Payers, however, argue the practice is critical to lowering skyrocketing healthcare costs by denying unnecessary care. There's evidence to back that claim up. A 2017 Government Accountability Office report found prior authorization saved Medicare as much as $1.9 billion from its beginning in seven states in 2012 through March 2017.
And PA typically applies to less than 15% of covered healthcare services, according to payer group America's Health Insurance Plans. AHIP says any additional overhead on providers is relatively uncommon and the scrutiny of PA pays off by weeding out unneeded care. Health insurers report almost 30% of PA requests are for care not supported by clinical evidence.
But red tape from prior authorization has gotten worse, clinicians argue. Nearly 90% of providers in the private sector told the AMA that the time and money devoted to clearing care with a patient's payer has grown over the past five years for their practice, likely because most PAs are obtained through traditional phone or fax methods.
Payers and providers alike agree PA needs reforming. Payer groups AHIP and the Blue Cross Blue Shield Association came together with the AMA, American Hospital Association, American Pharmacists Association and Medical Group Management Association to release a "Consensus Statement on Improving the Prior Authorization Process" last year.
One popular solution supported by the coalition is electronic prior authorization (ePA) which studies show leads to faster turnaround times, higher dispense rates and stronger medication adherence.
Electronic prior authorization could save the industry almost $420 million per year, with providers recouping roughly $280 million alone, according to healthcare business processes nonprofit CAQH. That's about $4 per transaction.
However, ePA adoption remains relatively low, at about half the market.
Rucker told Healthcare Dive there's a whole set of industry standards around ePA within health IT networks that simply aren't being used. The PA electronic transaction between two networks includes a claims attachment that's only filled in about 10% of the time, according to CAQH.
"The question is, why is it not used more?," Rucker asked.
Potential explanations for industry players not using the claims standard could include perverse economic incentives causing fee-for-service providers to favor more expensive care, regardless of whether it's covered by insurance. Other reasons ONC is looking into include that stakeholders simply don't have the right data, or enough of the right data, or any way to get it.
ONC is looking at ways to reintegrate disparate types of data within prior authorization as part of a larger policy push to stop information blocking between disparate health IT networks. The agency, along with CMS, released two interoperability rules earlier this year implementing key provisions of the 21st Century Cures Act in an attempt to foster increased data sharing within healthcare.