Health care policies and regulations are usually made out of good intentions. The irony is that even the most well-intentioned plan can create bottlenecks that can negatively affect patient care. The prior authorization (PA) established more than 50 years ago is such an initiative.
As the cost of healthcare in the United States continues to rise, regulators, payers, doctors, patients, and other stakeholders continue to seek opportunities to formulate and implement ambitious policies to make healthcare more affordable. PA was designed as a cost-saving strategy, but it has evolved into a barrier that hinders patients’ access to care, and has become a process that is usually time-consuming, opaque, confusing, and even “cumbersome”. Medical Group Management Association.
Prior authorization: background story
PA is the process of ensuring that insurance companies approve medical services or prescription drugs ordered by providers. It was originally designed to control costs and ensure that prescription drugs or recommended treatments are “necessary and appropriate.” When a PA is required, the patient’s insurance company will not agree to pay for the recommended treatment or drug until it issues authorization-this may take hours or days, and usually results in delays in treatment.
According to a The most recent AMA survey, 30% of doctors report that PA causes serious adverse events that affect their nursing patients, and 79% of doctors say that PA sometimes leads to treatment abandonment. Many doctors also believe that PA weakens their medical authority, while some patients believe that the process imposes additional constraints on their own care decisions.
As commonly implemented today, many doctors and patients believe that PA does more harm than good, because it is possible Delayed access Nursing, this can lead to impaired health outcomes.
Some of the challenges faced by traditional PA processes include:
- Inconsistent communication channels, Include telephone / fax, Email, text, voice mail and handwritten notes. A messy temporary “system” often leads to poor communication, delays in care, and even medical errors.
- Lack of integration with prescription workflow and electronic health record (EHR) systemPAs are often in silos outside of established electronic workflows and recording systems, which makes it difficult for providers to access key patient data that can inform PA decision-making. This lack of integration may delay care and impair the patient’s treatment effectiveness. ?
- The management time for PA processing is too long. On average, the weekly PA management tasks require two working days for doctors and staff, otherwise these hours could have been dedicated to patient care.one AMA survey??? Report? 40% of doctors have two full-time staff engaged in PA.
Legislation + CMS rules: a step in the right direction
Suppliers, regulators, patients and other stakeholders have long been demanding to be aggressive Amendment of PA, Including greater transparency, accelerated decision-making, and standardization of practices and policies. Proposed CMS rules New requirements for various Medicaid and CHIP programs and Qualified Health Plan (QHP) issuers to improve the electronic exchange of healthcare data and simplify PA-related processes. By 2023, payers will need to upgrade their systems to make PA transparent, easy to understand, and available to patients and providers.
In addition, Congress also proposed Laws to improve timely access to care for the elderlyThe bill includes requirements for private insurance companies operating Medicare Advantage plans to establish an electronic prior authorization (ePA) process to approve medical services and drugs faster, and provides for greater transparency for beneficiaries and providers.
Although both measures are expected to improve the PA process for certain populations, the reality is that all patients (regardless of the payer) need and deserve similar relief. Patients of all ages and insurance coverage need to get care in time and get rid of the red tape that has become synonymous with PA.
The next valuable work is to automate PA for all payers and incorporate ePA into EHR and prescription workflows.
How ePA can help
By automating the PA process, patients can receive care faster, clinicians can make more informed care decisions, and management troubles can be minimized. Electronic PA, according to 2021 AHIP research, It has been found that the average time from PA request to decision has been reduced by 69%. In addition, 71% of providers using ePA report “providing patient care faster”.
Electronic PA automates manual processes, thereby reducing the possibility of errors and saving staff time. Because ePA provides a direct connection to the payer, the provider has more complete and up-to-date detailed information about patient benefits in the prescription workflow. With easy access to PA guidelines, clinicians can make more informed decisions to support faster access to care and better patient outcomes.
As the industry considers alternatives to improve PA efficiency, clinicians need ePA solutions to support existing workflows and provide:
- Full details about the patient’s eligibility profile, including unmet deductibles and co-payments
- Access current PA requirements for specific drugs and treatments in the workflow
- Out-of-pocket expenses for alternative therapies when prescribing to support informed discussions between clinicians and patients
It’s time to provide the best care for all patients by repairing the PA
Although the initial goal of PA may be well-intentioned, the inefficiency of the traditional PA process can have a negative impact on patient care and harm the efficiency of clinicians. However, by adopting ePA, stakeholders can streamline clinicians’ workflow, support more informed care decisions, increase the transparency of patients and clinicians, and ultimately drive better clinical outcomes.
