Stakeholders Sign On for Simplification
Not every major action takes an act of legislation.
Last month, a number of major health associations and payer organizations released a consensus statement to streamline prior authorization and simplify processes to improve timely care while reducing administrative burdens. Recognizing pre-approvals play an important role in dispensing evidence-based, cost effective care, the organizations also noted the processes vary considerably and can be unduly burdensome to providers, payers and patients.
In an effort to streamline the approval process and enhance transparency and communication, the American Hospital Association (AHA), America's Health Insurance Plans (AHIP), American Medical Association (AMA), American Pharmacists Association (APhA), Blue Cross Blue Shield Association (BCBSA) and Medical Group Management Association (MGMA) released a outlining their shared commitment to industry-wide improvements to prior authorization processes and patient-centered care.
"America's hospitals and health systems are committed to delivering the best care for patients in the most efficient manner, goals we share with our partners in the health field," said Tom Nickels, executive vice president of the AHA. "These principles provide a good starting point for providers and health plans to work together toward continuous improvement in quality of care and health outcomes while reducing unnecessary administrative burden."
The collaborating organizations have identified five key areas where there are opportunities for improvement and have agreed to work together to encourage or improve the processes related to each area as outlined below:
- Selective Application of Prior Authorization: reduce the number of healthcare professionals subject to prior authorization requirements based on their performance, adherence to evidence-based medical practices, or participation in a value-based agreement with the health insurance provider.
- Prior Authorization Program Review & Volume Adjustment: regularly review the services and medications that require prior authorization and eliminate requirements for therapies that no longer warrant them.
- Transparency & Communication Regarding Prior Authorization: improve channels of communications between health insurance providers, healthcare professionals, and patients to minimize care delays and ensure clarity on prior authorization requirements, rationale, and changes.
- Continuity of Patient Care: protect patients who are on an ongoing, active treatment or a stable treatment regimen when there are changes in formulary, coverage, health insurance providers or prior authorization requirements.
- Automation to Improve Transparency & Efficiency: accelerate industry adoption of national electronic standards for prior authorization and improve transparency of formulary information and coverage restrictions at the point of care.
In January 2017, the AMA and 16 other associations representing physicians, medical groups, hospitals, pharmacists, and patients intended to reduce the administrative burdens associated with prior authorization and to ensure that patients receive timely and medically necessary care and medications. More than 100 other healthcare organizations have since supported those principles, providing the impetus to launch the discussions with the health insurance industry that led to the current consensus statement.
"This collaboration among healthcare professionals and health plans represents a good initial step toward reducing prior authorization burdens for all industry stakeholders and ensuring patients have timely access to optimal care and treatment," said AMA Chair-elect Jack Resneck, Jr., MD.