In today’s prior authorization system, “coverage is not access”

The panel said the prior authorization system was intended not only to ensure that the treatments are necessary, but also to ensure that the practices are paid for; however, it needs a lot of work.

Prior authorization requirements in cancer care have become so onerous that payers are essentially making coverage decisions one case at a time, according to a panelist who participated in the session, “Prior Authorization: How Sausage Is Made “, which drew a large crowd. Thursday at the 2022 Association of Community Cancer Centers Annual Meeting and Cancer Center Business Summit, held in Washington, DC.

Collectively, the panel moderated by Ira Klein, MD, MBA, FACP, Vice President of Medical Affairs and Payer Relations, Tempus Labs, said the system needs a lot of work. Andrew Hertler, MD, chief medical officer of New Century Health, said the system is intended not only to ensure that treatments are needed, but also to ensure that practices are paid for.

But other panelists said pre-authorization requires practices to make costly investments in staff and software to navigate payer requirements, and they argued that moving to risk-bearing practices should make this outdated bureaucracy.

Prior authorization has become so broken in healthcare that “coverage itself is not access,” said John Hennessey, MBA, CMPE, senior vice president and strategist, Valuate Heath Consultancy. He explained that pre-authorization transactions happen all the time, but most are transparent, like handing a credit card to a hotel employee, who makes sure the bill can be paid before customer registration.

In health care, the process is both slow and unpredictable. “Pre-clearance at some point was intended to protect people from low-value experiences,” Hennessey said. “When these transactions go wrong and they happen with great uncertainty, that value is lost.”

Being told “no” repeatedly tells a practitioner and patient that the services or medications they cannot have must be really good. So, by their behavior, payers are sending the wrong message, Hennessey said. “So that part of the process is broken,” he said.

Lalan Wilfong, MD, executive vice president, Value Based Care & Quality Programs, Texas Oncology, and vice president of payer relations and practice transformation at McKesson Specialty Health, said he heard all the payers claim that the next portal would be better – and that’s never true. But most importantly, he said, prior authorization represents “the insertion of an entity into care that comes between you and the patient.”

“There must be better solutions,” Wilfong said.

Klein, who previously worked for a payer, said pre-authorization has an appropriate role — if the payer handles claims for a self-insured employer, for example, a stop-loss insurer needs to be notified before a claim does not become too important. But when patients are diagnosed with cancer and then told it’s not clear they can get the diagnostic tests or treatment recommended by their doctor, it becomes overwhelming.

Are there solutions to the current system?

Wilfong said he doesn’t see a problem documenting the reasons for non-compliance with guidelines when it happens in a small percentage of cases. Regional payers are more willing than national payers to be flexible by giving practices the freedom to avoid pre-clearance in exchange for taking on risk, he said. Texas has also created a “gold card” system, which exempts firms from prior authorization if 90% of their claims have been approved during the previous 6 months.

Hertler sees possibilities with artificial intelligence, which would use electronic health record information to speed up decision-making. But when conversations are needed, Hertler said oncologists should be able to speak with other oncologists at the payer level, instead of having to explain the need for a drug to a medical director with no experience in cancer care. Cancer.

“It’s a trust and verification system,” Wilfong said.

Hennessey said pre-authorization shouldn’t be used as a hammer to replace the fact that some payers have poor prices in certain areas or at certain hospitals.

Finally, Wilfong said, payers must stop subjecting practices that have assumed risk to the misaligned incentives found in health care. He used an example that currently plagues many oncologists: Anthem is telling practices that they should use more expensive rituximab instead of less expensive biosimilars.

“The use of pre-authorization for form management is inappropriate,” he said. “We all know exactly what’s going on here.” Practices, he said, will be required to carry more brands of rituximab and have more refrigerators, and nurses will need to be familiar with more formulations.

Hertler agreed, saying the discounts threatened to undermine the practices’ ability to manage costs with biosimilars. “The discounts go to one place and someone else pays the cost,” he said. “If I could take discounts out of the world, I would.”

He sees hope in the endorsement of care “groups”; for example, a patient with non-small cell lung cancer would be approved in advance for diagnostic tests, scans at designated intervals, and treatment.

Panelists discussed abuse with staged changes, and Klein sees challenges in the diagnostic space.

“It’s not about which product is better, but which has the better discount for the payer,” Hennessey said. “If anyone takes offense, I’m sorry, but that’s what’s happening. One of the challenges is, while we as healthcare providers try to take care of patients to simplify this process, sometimes things beyond our control make it much more complex. And prior authorization, in some cases, becomes almost a contract negotiation on a patient-by-patient basis.

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