Dr. Paul Harari, a radiation oncologist, likened it to torture. The interminable back and forth. The outdated fax machines. Wasting time on the phone to convince a health plan’s medical director that a cancer treatment the plan denied is the right way to go when he could be off taking care of his patients.
Harari’s frustration with prior authorization is typical among doctors and other clinicians, who say they are increasingly burdened with onerous requirements imposed by health insurers and pharmacy benefit managers to seek advance approval for procedures and medications. They claim the requirements harm patients in the name of boosting insurers’ profits.
“Cancer patients are super anxious about delays and that’s what we continue to see more and more of with prior authorization: delays in getting recommended treatment underway,” said Harari, chairman of the human oncology department at the University of Wisconsin School of Medicine and Public Health in Madison.
Health insurers and other payers insist prior authorization is a tool used sparingly to ensure patients are getting the right treatment in the right place; reducing costs is secondary. They contend it’s not a means to deny claims, as HHS’ Office of Inspector General has suggested. But they do admit the cumbersome process is a pain, and some insurers are at the center of collaborative industry initiatives to modernize the process.
Momentum is finally building behind those efforts. Health plans, providers, electronic health record vendors and federal agencies are working together to reduce the prior authorization burden by automating it. Other organizations are experimenting with reducing the sheer volume of authorization requirements foisted on doctors. Congress, meanwhile, is eyeing a legislative fix that aims to do a little of both.
But prior authorization is just one element of a bigger problem—the “shiny object” in the middle of a broader movement to reduce administrative burden and costs, said Alix Goss, co-chair of the Standards Subcommittee of the National Committee on Vital and Health Statistics, one of the organizations involved in the efforts.
Fixing it could make doctor and insurer interactions more efficient beyond just prior authorization and lead to advances that have so far eluded the U.S. healthcare system, including price and quality transparency and value-based payment, experts say.
“This needs to be not just about how we fix the widget of prior authorization,” Goss said, but about “how we converge the clinical and administrative and financial data and related standards to better meet the needs of our healthcare system and its emerging business models.”