Prior Authorization: Care Assessments That Help Patients Receive Effective, Safe, and Affordable Care
The doctor-patient relationship works best when there is a foundation of trust. When patients experience unexpected costs, unnecessary tests, long wait times for care, and confusing communications, that trust is eroded. As physicians in family and internal medicine with a combined 70+ years of practice, we have dedicated our careers to patient care, offering clinical expertise, compassion, and respect. But as an industry and as a country, we haven’t set up a system that allows us to deliver on these promises to our patients consistently.
The rising cost of health care is a paramount issue affecting every American household. Some rises in cost are unavoidable. Hospitals, for example, are experiencing significant increases in expenses necessary to offer care. We recognize these challenges that our industry partners are confronting. Other costs, however, are not only avoidable but also result in negative outcomes for patients.
Thirty percent of all heath care spending in the United States may be unnecessary, for example, and in many cases can be harmful to patients. Indeed, every year low-value care costs the U.S. healthcare system $340 billion. Eighty-seven percent of doctors have reported negative impacts from low-value care.
As physicians who serve within health plans and have provided patient care, we are able to address low-value care through utilization management, or prior authorization. When done right, prior authorization can quickly and fairly assess treatment recommendations for patient benefit in terms of quality, safety, and effectiveness. These assessments are done in the light of up-to-date medical best practice research. Performed in advance of a doctor ordering a test, procedure, or medication, prior authorization can identify and re-direct low-value care to better alternatives, resulting in fewer unnecessary interventions, fewer unnecessary medical bills, and better outcomes.
We support policies that improve the process for health plans to perform prior authorizations, easing provider administrative burdens, such as electronic transmission. In 2018, stakeholders representing providers, pharmacists, and insurance providers developed a Consensus Statement recommending opportunities to improve the prior authorization process. Since then, health insurance providers have taken extensive steps to improve the process for patients and providers alike and will continue to do so.
We recognize that there is often a misperception associated with prior authorization. For some, this intermediary assessment seems to come between the physician-patient relationship. Others, including some of our fellow doctors, have dismissed these pre-service care assessments as time intensive and not necessary. Yet, 65% of physicians have said that at least 15-30% of medical care is unnecessary.
Recently, the New York Times shared the tragic story of a patient who underwent a procedure by a Michigan doctor operating outside of the standard practice for vascular care. Sadly, the procedure resulted in the need for a leg amputation. According to the reporting, 45 people lost their limbs over the last four years as a result of this particular doctor performing risky, costly, and unnecessary vascular procedures.
Most doctors do not practice outside acceptable standards, but it does happen. The vast majority of physicians are acting in good faith – but there are times when even the best doctors don’t have a complete picture of other treatments a patient might be receiving.
We discourage state and federal policymakers from preventing health plans from engaging in this important role to promote safe, effective, affordable patient care. We understand that some lobbyists are pushing to erode the oversight that health plans exercise over low value care, trying to remove even the most basic guardrails. This is a precarious path that could increase the prevalence of low value care, make valuable care more cost prohibitive, and increase the risk of adverse events.
As doctors serving at health plans who also have experience caring for patients, our goal is the same as that of our colleagues who directly deliver care—first do no harm. To protect patients, we strive to ensure that the right care is delivered at the right time in the right setting – and covered at a cost that patients can afford. We uniquely understand the important care and life-saving treatments doctors provide, but like everyone in health care, they should not be above oversight.
Prior authorization provides needed oversight. That’s why changes to the healthcare system must put patients first – and protect both their health outcomes as well as their financial security. For our part, we will continue to collaborate with providers and other stakeholders to ensure patients receive safe and affordable care.
Dr. Robert Gluckman, MD, MACP is the former Chief Medical Officer for Providence Health Plan and Dr. Timothy D. Law is the CMO of Highmark, Inc.
