Streamlining and Reimagining Prior Authorization Under Value-Based Contracts: A Call to Action From the Value in Healthcare Initiative’s Prior Authorization Learning Collaborative

Abstract

Utilization management strategies, including prior authorization, are commonly used to facilitate safe and guideline-adherent provision of new, individualized, and potentially costly cardiovascular therapies. However, as currently deployed, these approaches encumber multiple stakeholders. Patients are discouraged by barriers to appropriate access; clinicians are frustrated by the time, money, and resources required for prior authorizations, the frequent rejections, and the perception of being excluded from the decision-making process; and payers are weary of the intensive effort to design and administer increasingly complex prior authorization systems to balance value and appropriate use of these treatments. These issues highlight an opportunity to collectively reimagine utilization management as a transparent and collaborative system. This would benefit the entire healthcare ecosystem, especially in light of the shift to value-based payment. This article describes the efforts and vision of the multistakeholder Prior Authorization Learning Collaborative of the Value in Healthcare Initiative, a partnership between the American Heart Association and the Robert J. Margolis, MD, Center for Health Policy at Duke University. We outline how healthcare organizations can take greater utilization management responsibility under value-based contracting, especially under different state policies and local contexts. Even with reduced payer-mandated prior authorization in these arrangements, payers and healthcare organizations will have a continued shared need for utilization management. We present options for streamlining these programs, such as gold carding and electronic and automated prior authorization processes. Throughout the article, we weave in examples from cardiovascular care when possible. Although reimagining prior authorization requires collective action by all stakeholders, it may significantly reduce administrative burden for clinicians and payers while improving outcomes for patients.

Patient administrative burden in the US health care system

“…31 Simplifying prior authorizations has been recognized as a policy priority by medical and insurance groups. 32,33 4. Billing issues.…”

Strategies to Reduce Low-Value Cardiovascular Care: A Scientific Statement From the American Heart Association

“…First, the administrative burden on clinicians to obtain approvals for high-value tests and treatments is significant. 81 Many cardiovascular clinicians are frustrated by the time, money, and resources required for prior authorization processes. Even more frustrating can be the frequent denials (often from clinicians who are not cardiovascular specialists), the perceptions of being excluded from the decision-making process, and the feelings of less-than-adequate care provided to patients.…”

“…Redesign the prior authorization process by reducing or removing its administrative burden on clinicians, removing barriers to appropriate access to patients, and reducing its potential to worsen disparities in care among underserved patients and patients of color. 81,83,134…”

A comprehensive framework for navigating patient care in systemic sclerosis: A global response to the need for improving the practice of diagnostic and preventive strategies in SSc

“…Prior Authorizations (PAs): Advocacy for streamlining PAs [96] is essential to improve patient survival and outcomes. Further, denials lead to higher insurance company costs [97], as most clinicians finally attain authorization [98].…”