Insurers tout the benefits of prior authorization, citing some studies showing reductions in costs and unneeded care, but providers still tend to balk over concerns of excess paperwork and patient care.
Now, some are pushing moving PA to EHRs to ease administration and mitigate potential harm to patients. It comes as a diverse group of stakeholders, including some who've blasted the practice like the American Medical Association, are coming together to find common ground.
The AMA, American Hospital Association and America's Health Insurance Plans are among the signers of a recent consensus statement noting their "shared commitment to industry-wide improvements to PA processes and patient-centered care."
The practice is under renewed scrutiny as insurers like Anthem have doubled down on efforts to restrict coverage of some procedures and care settings. Earlier this year, Aetna's PA policy was called out when a former medical director said in court documents he didn't review patient medical records before deciding on authorization.
At the same time, CMS just encouraged MA plans to use PA to cut down on the use of pricey drugs administered in doctors' offices via Part B of Medicare.
Costs versus care?
A Government Accountability Office report released this year said Medicare PA saved between $1.1 billion and $1.9 billion through March 2017.
But PA can cause delays in care and result in patients not getting needed prescriptions. CoverMyMed’s 2018 ePA National Adoption Standard found about 10% of prescription claims are rejected at the pharmacy. About 300 million prescriptions require PA and patients abandon 36% of those prescriptions because of complexities or inefficiencies in the process, the report said.
Insurers argue that the needle can be threaded, with PA preventing overuse and protecting patients at the same time.
Cathryn Donaldson, communications director at AHIP, said it can also ward against doctors practicing defensive medicine, such as ordering potentially unnecessary tests to avoid a lawsuit. "Patient care must be based on proven evidence and medical management promotes smart and safe patient care," Donaldson said.
At the same time, EHR companies are selling their products as potential solutions to prevent patients from failing to take their meds because of PA hurdles. "It’s a huge adherence problem," Luke Forster-Broten, manager of product innovation at Surescripts, told Healthcare Dive.
Still, many providers view PA as a nuisance.
The Academy Academy of Family Physicians called the practice family physicians' "number one administrative burden."
"Prior authorizations create significant barriers for family physicians to deliver timely and evidenced-based care to patients by delaying the start or continuation of necessary treatment," the AAFP said.
An AMA survey earlier this year found that 92% of physicians reported that PAs hurt patient clinical outcomes. Among the findings: Nearly one-third of doctors surveyed said they waited at least three business days for a payer to give the OK and medical practices surveyed said they deal with an average of 29.1 PAs a week.
The Council for Affordable Quality Healthcare (CAQH), a group of stakeholders that includes more than 130 health plans, hospitals, health systems and vendors, estimates that electronic transactions can save $6.84 per transaction.
Surescripts and CoverMyMeds say they can let providers complete a request within minutes. In many cases, the plan bakes the ePA system into EHRs.
Forster-Broten said payers structure ePAs so that providers can't physically send an incomplete question set, reducing the need for a later back-and-forth. "You’re getting all the information you need the first time and then you're able to run that through your system and then move as many of those prior authorizations to an automated process, so it cuts down on the amount of time," he said.
Two recent ePA case studies highlight the potential benefits of ePA.
A recent case study of Milwaukee area nonprofit Aurora Health Care's ePA system from Surescripts found that patients got prescription drugs quicker. Plus, there was less administrative work for providers. The program reduced the PA process from more than 3.8 days to 1.4 days, improved the time from 22 to 12 active minutes, improved physician, nurse and organizational buy-in and decreased overtime costs by 20%.
Forster-Broten said Surescripts has seen a 1% increase in first-fill adherence for patients where ePA is available. In Aurora's case, the system enjoyed an 8% first-fill adherence after a few months.
Another case study involved CoverMyMeds and Mercy Health. The ePA saved an average of 2.9 hours per prior authorization over a six-month period. The average turnaround time decreased by 25% in that period.
Scott Gaines, SVP and GM of provider solutions for CoverMyMeds, told Healthcare Dive that the ePA platform saved time by providing features like customized question sets, auto-populated provider and patient information and auto-determination functionality.
Bob Bowman, director of CAQH, told Healthcare Dive that ePA can make a massive difference in the pharmacy sector. The industry must "learn how automated systems and applications through concerted industry effort can drive down administrative costs and improve provider/patient interactions and provider/health plan relationships."
Future of ePA
HHS has designated CAQH CORE (a subunit of the stakeholder group) to author federally mandated operating rules for electronic exchange and use of health information, and Bowman is optimistic the group's Phase IV Operating Rules and Phase V Operating Rules will help move the industry into streamlining the PA process. He said that phase dealt with establishing requirements of response times, connectivity, acknowledgment of requests and real-time and batch processing. Phase V will build upon that.
"When finalized, Phase V CAQH CORE Operating Rules will ensure electronic prior authorization contains the information needed by providers and health plans to reduce the need for manual follow-up," Bowman said.
With pharmacy ePA becoming more of the norm, the next frontier is faster decisions on tests and procedures. Forster-Broten said ePA for medical benefits is more complicated. For prescriptions, the process requires working with a couple dozen PBMs, as a handful of companies constitute most of the PBM market. However, when dealing with tests and procedures, things get much more difficult because there are hundreds of health plans.
"There's not a good industry solution right now for prior authorizations on the things that are covered under medical benefits. There are lots of companies trying to make that happen, though," Forster-Broten said.