The ACR recently partnered with the American Medical Association (AMA) and a coalition of 16 other organizations representing physicians, medical groups, hospitals, pharmacists and patients to dramatically reshape prior-authorization protocols.
The coalition is urging an industry-wide reassessment of these protocols to align with a newly created set of 21 principles, called the Prior Authorization and Utilization Management Reform Principles, with the goal of removing barriers that may delay or deny treatment and negatively affect patient outcomes.
According to a new AMA survey, every week a medical practice completes an average of 37 prior-authorization requirements per physician, which takes staff the equivalent of two business days to process.
“These are general principles that doctors agree with and that insurance companies should abide by,” says Angus B. Worthing, MD, FACP, FACR, a rheumatologist at Arthritis & Rheumatism Associates and clinical assistant professor of medicine in rheumatology at Georgetown University in Washington, D.C., as well as chair of the ACR’s Government Affairs Committee.”The principles help patients get the care they need as efficiently as possible and free up doctors’ offices to take care of patients instead of focusing on paperwork.”
Categories & Critical Principles
Dr. Worthing, who was involved in reviewing and vetting the 21 principles on behalf of the ACR, says these common-sense concepts are grouped into five broad categories: 1) clinical validity; 2) continuity of care; 3) transparency and fairness; 4) timely access and administrative efficiency; and 5) alternatives and exemptions.
Although all are important, he says Principles 1 and 3 are especially critical:
- Principle #1: Any utilization management program applied to a service, device or drug should be based on accurate and up-to-date clinical criteria and never cost alone. The referenced clinical information should be readily available to the prescribing/ordering provider and the public.
- Principle #3: Utilization review entities should offer an appeals system for their utilization management programs that allows a prescribing/ordering provider direct access, such as a toll-free number, to a provider of the same training and specialty/subspecialty for discussion of medical necessity issues.
He explains that rheumatologists and patients jointly decide which medication should be used on the basis of multiple factors, such as the patient’s past medical history or whether they’re able to self-administer a drug. Principle 1 recommends that insurers base their decision on accurate and up-to-date clinical criteria rather than cost alone. Likewise, Principle 3 advocates that if an insurance policy conflicts with a physician’s decision, then the appeals process should be clear and involve a health plan employee who is trained in rheumatology, because this would help avoid a prolonged process and prevent a patient’s illness from growing worse.
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.
