A Questionable Future
Some principles also address grandfathering in relation to treatments or specialty drugs. Take Principle 4, which states that if patients are stabilized on a particular treatment or drug, their therapy should not be interrupted for a minimum of 60 days while utilization management requirements are being addressed.
Other principles cover transparency and fairness involving timely access to formulary information, or circumvent prior authorizations for physicians who use proven, clinically based pathways to appropriately treat inflammatory diseases.
Principle 20 expands on this concept by requesting health plans to develop alternative, less costly options that serve similar functions to prior authorizations.
“In the coming era of paying doctors for valuable care instead of fee for service, the concept of prior authorizations might even go away,” says Dr. Worthing. “If physicians begin taking on risk for their clinical decision making and are following nationally agreed-upon guidelines, they shouldn’t be forced to participate in insurance formularies and prior authorization processes.”
A Call to Action
Looking ahead, the coalition welcomes the opportunity to work collaboratively with health plans and others to lay the foundation for a more efficient prior authorization process. Dr. Worthing adds that this also presents a great opportunity for all physicians to get involved in healthcare reform.
“When rheumatologists see that the overall house of medicine is coming together to reform prior authorizations in a way that improves their day-to-day practice and gets treatment to patients more effectively, they’ll be motivated, hopefully, to stay or get involved in the process of working with payers, elected officials and other government leaders,” he says. “It’s really up to us to protect healthcare in the U.S.”
Carol Patton is a freelance writer based in Las Vegas.
