Talk to just about anyone who has had an encounter with our health care system and, most likely, they will tell you about the headaches they faced getting prior authorization. Insurers are increasingly using prior authorization to delay and deny all sorts of care inappropriately in order to maximize profits. There’s a better way, writes Michele Kowalski-McGraw, MD, et al. in an opinion piece for MedPageToday.
Too often insurers say they will not cover life-saving care or life-improving care. They claim that prior authorization keeps health care costs down because they make sure they are not paying for unnecessary care. They try to keep you from believing that they are endangering their enrollees’ health and well-being.
Prior authorization also costs our health care system–patients, as well as physicians and hospitals– billions of dollars each year. Patients have to pay for care that should be covered. Physicians and hospitals spend time and money working to get approvals for needed care. Almost one in four doctors say that prior authorization creates “serious adverse” outcomes for their patients.
And, prior authorization creates physician burnout. A team of physicians, the End Burnout Group (EBG) proposes a way to reduce unnecessary care in ways that help patients and physicians, while reducing administrative costs. They want to use national clinical guidelines for certifying whether a procedure is appropriate. Put differently, they want to implement a standardized system that verifies whether a procedure meets clinical guidelines.
Evidence-based Care Optimization (ECO) is an alternative to prior authorization. Rather than assume that the care is not needed, ECO assumes that the treating physician is delivering needed care unless the clinical evidence shows that clinical guidelines do not support the care being proposed. If there are no guidelines, ECO assumes the care is needed.
If there are clinical guidelines, the data in a patient’s electronic health record (EHR) determine whether the care is appropriate based on those guidelines. If more data is needed, the physician can update and revise information quickly.
With ECO, the insurers are not deciding what is clinically appropriate, as they do with prior authorization. The insurers are responsible only for letting clinicians know whether their services are covered, the amount of coverage and payment. There is no insurer conflict of interest.
ECO, as imagined, would be an open-source project. It would require no additional tools to determine whether EHR documentation is in keeping with clinical guidelines. The Agency for Healthcare Research and Quality has said that real-time decision support is feasible, drawing from a centralized source that houses the clinical guidelines.
Of course, a governing body would need to oversee ECO guidelines as they develop. The End Burnout Group believes that this oversight body should be independent of medical societies but include representatives from all societies.
Here’s more from Just Care:
- How to keep insurers from denying Medicare Advantage enrollees needed care
- Oncologists report excessive deaths from prior authorization
- Prior authorization in Medicare Advantage harms patients, sometimes severely
- OIG finds widespread inappropriate care denials in Medicare Advantage
- New physician survey finds prior authorization harms cancer patients
