More data regarding the effectiveness of medical treatments gets collected and analyzed every year, and payers are using this information to approve and deny specific prescription drugs and medical procedures. This value-based approach to care should be a benefit to everyone, but there's concern among some physicians that prior authorizations are leaving patients with unique circumstances behind. In order to fulfill their oath to deliver the best possible care to patients, doctors will need to adapt to this new payment methodology by making sure payers hear their voices.
The Prior Authorizations Process
Each insurance company has different prior authorization policies, but as a whole, the industry follows guidelines established by America's Health Insurance Plans (AHIP). Payers take an evidence-based approach to find which drugs, devices, and other care options produce results while giving significant weight to proven clinical trials and FDA approval. Ideally, practicing nurses and doctors work with insurance companies to constantly adapt what is or isn't approved in response to new information. Industry representatives claim that all decisions in this area are made with careful consideration for safety and affordability.
Why Physicians Are Concerned
The fundamental concept behind value-based care - improving outcomes - is something that almost all physicians find constructive. Giving care providers incentives to use drugs and treatments that are proven by data to be effective is a positive thing. Problems can arise, however, with patients who don't respond in predictable ways to treatments that have prior approval. It's also a problem for patients who show atypical outcomes from unapproved care. Many patients face almost entirely unique situations that require a hands-on approach from a physician with access to a wide variety of resources.
Physicians don't believe their clinical decisions should be primarily decided by whether or not a treatment option will be approved by the patient's insurance company. This is an unfortunate reality in the current value-based care system because insurance payments have a huge impact on the financial solvency of healthcare providers. Many physicians argue that they should have the power, much like they did in the past, to provide the best care for patients without having to worry about being reimbursed. Value-based care, they argue, will work best when doctors have more input on the authorization process.
Getting Physician Voices Heard
Groups representing insurance companies, pharmaceutical brands, and physicians, including AHIP and the American Medical Association, are starting to work together to streamline the prior authorization process. Together, these groups issued a statement in early 2018 to announce that they were striving to "promote quality and reduce unnecessary burdens," in the system. They also made a pledge to work together to achieve five goals:
- Decrease the number of physicians and other healthcare professionals who must adhere to prior authorization requirements.
- Routinely review medications and treatments to see whether they still warrant prior authorization.
- Improve and increase honest communication between payers, doctors, and patients.
- Ensure that patients benefiting from continuity of care are protected when changes are made to their coverage or relevant prior authorizations.
- Make it clear how and why specific drugs and treatments are denied or approved while increasing adoption of electronic health record sharing (EHR).
One of the most important goals for fixing value-based care issues is to give doctors with proven track records of success the freedom to make their own decisions. It's not in anybody's interest to heavily scrutinize an effective physician when they're prescribing drugs or performing tests. It wastes time and money and reduces the patient's chance of improving. Reducing the instances where healthcare providers make choices just to save money is key.
The Battle for Proper Reimbursements
While it's important for doctors to push for a greater role in value-based care, many of the tactics for getting reimbursed in the fee-for-service model are still effective. In many cases, a treatment option is denied because a provider didn't fill out all the necessary information. Simple improvements to record keeping can increase reimbursements. In situations where patients might benefit from care that's not supported by an abundance of evidence, doctors can often gain approval by speaking with the medical professionals who work at the insurance company.
Physicians who have a history achieving positive outcomes and avoiding denials may be able to negotiate contracts that provide automatic approval for treatment of specific conditions. When it comes to treating conditions they're less familiar with, they can benefit from the evidence-based approaches utilized in the value-based system. Both payers and private EHR companies offer powerful clinical decision-making tools. While the current value-based model is far from perfect, greater collaboration between all those involved is crucial.