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Health Care Journalist’s Guide to Prior Authorization

This The article was updated on December 27 with a section on prior authorization requirements for HIV prevention drugs.

Doctors and insurers in the United States often disagree about whether people should receive certain medical treatments, including prescription drugs. Consumers are sometimes drawn directly into these battles when insurers challenge doctors’ decisions in a process called prior authorization.

In many cases, health insurance plans cover procedures and drugs prescribed to patients. Often, however, insurance companies demand additional information from doctors and other medical professionals to justify their prescriptions and orders. In the medical field, this is called prior authorization or preauthorization.

Health insurance companies argue that this process can reduce unnecessary procedures and health care costs. Health plans use it as a tool, for example, to screen for potentially addictive pain relievers is being used appropriately as part of a national response to the opioid crisis.

But doctors are critical of how insurers design their processes for handling prior authorization requests. They have expressed concern both about the frequency of these requests, even for routine procedures, and the administrative burden they face due to the demand to spend hours on the telephone or fax documents to insurance companies.

In health cases. October 2020, David Cutler, professor of applied economics at Harvard University, writes about what he considers the “unnecessarily complicated” procedures used. In prior authorization as an aspect of medicine in need of improvement. For example, an insurer may ask a doctor for more information about a patient before approving a radiology test. But much of the information sought may already be in the patient’s electronic medical record and can be communicated more easily to the insurer’s review staff through this route. But health plans instead require a more cumbersome, relatively outdated approach that often involves faxes and phone calls.

“To document this, the provider’s office must fax information from the medical record to the insurer, who then reviews everything. Before reaching a decision, Cutler writes in his blog post, titled “Taming the Paper Tiger.” “A more streamlined way to do this is for the provider’s EMR system to verify that the patient meets the relevant criteria, avoiding all human interaction.”

AA 2020 survey of 1,000 doctors by the American Medical Association, 58% of phone calls with insurance companies often or always complete prior authorization requests for prescriptions was required, 59% said this was true for prior authorization requests for medical services. Regarding faxes, 48% of respondents said these were always or often necessary, while 46% said this was the case for requests for medical services.

“It looks like it’s designed to make every step in the process. Patients are less likely to receive the therapy that doctors think they need,” Dr. Susan Bailey, then president of the AMA, said in Interview with Medscape Medical News. “It’s almost like rationing care by pitting patients and physicians against each other.”

Bipartisan support for streamlining the prior authorization process

There is broad agreement that the process needs reform. Physician organizations, including the AMA, have persuaded many members of Congress of the need for reform in the pre-authorization process, at least in terms of managing insurer-run programs Medicare benefits For people, known as benefit plans.

A House bill introduced in May, intended to speed up the previous authorization process, has bipartisan support. Received. .

The Timely Access to Care Reform Act (HR 3173) for Seniors has the support of 141 Democrats and 111 Republicans, or more than half of the members of the House of Representatives. December 20. You See here which members of Congress have sponsored the House bill. A companion Senate measure had the support of five Republicans and six Democrats, according to as shown herein.

These bills would address pre-authorization procedures only for insurer-operated Medicare plans. These plans cover about 26 million people in the United States, According to estimates by the non-profit Kaiser Family Foundation. Most people on Medicare are age 65 and older. Groups supporting these bills, including the American Medical Association, expect a ripple effect among health plans: If they are forced to simplify prior authorization for their Medicare Advantage programs, they could do so for their other health plans as well.

Specifically, the bills would push for the use of electronic pre-authorization programs, moving away from the use of faxes that frustrate many doctors. The bill would also direct Medicare to require Advantage plans to design systems that can issue “real-time” decisions on preauthorization requests.

Insurers have also voiced the need to streamline processes for prior authorization.<

In 2018, the trade group America’s Health Insurance Plans joined another large insurance group, the Blue Cross Blue Shield Association, in issuing a public statement on the need for reform. The AMA, American Hospital Association, American Pharmacists Association and Medical Group Management Association also signed on to the statement.

“The prior authorization process can be burdensome for all involved — healthcare providers, health plans, and patients,” Insurance and medical groups said in their joint statement.

In a 2018 consensus statement, insurers agreed to take steps to try to streamline the process, including removing barriers for doctors. with solid track records to prescribe appropriately.

“Unfortunately, we have not seen any progress from life insurers on reforms from the Consensus Statement agreed upon more than 3 years ago,” Dr. Jack Resneck Jr., president-elect of the AMA, told a reporter’s source in an email.

Meanwhile, insurers have expanded their use of prior authorization requirements in response to rising drug costs. These restrictions applied to about 24% of drugs in 2019 through insurer-run Medicare pharmacy programs, known as Part D plans, up from 8% in 2007, Resneck wrote in a February 2020 outlook article in JAMA, citing a federal advisory panel. . His article, titled “Refocusing Drug Prior Authorization on Its Intended Purpose, describes how insurers approach managing this process. . frustrates consumers and medical professionals.

“Frequently changing formularies and the ambiguity of prior authorization requirements mean that physicians may not know which treatment options will be filled without delay,” writes Resneck, who is also a professor and vice president. chair of dermatology at the University of California, San Francisco.

“Patients who come to pharmacies to pick up medications and start treatment are sometimes surprised to learn that additional action is required by their physician to obtain health plan approval,” continued Resneck. 6.” Thus begins a process that often involves faxes sent from physician offices to health plans, initial denials, written appeals, and sometimes ‘peer-to-peer’ telephone calls with decision makers who are not familiar with the disease or drug in question. Suggest inappropriate alternatives.”

Prior authorization requirements for HIV prevention drugs

Democrats in both houses of Congress are seeking to eliminate prior authorization requirements for HIV prevention drugs under private and public health insurance plans. As of December 27, Representative Adam B. Schiff (D-CA) had 43 Democratic sponsors for her version of a bill that would do this, while Sen. Tina Smith (D-MN)  One for Bill’s version.

Dr. Kathleen A. McManus of the University of Virginia and colleagues published in June 2012 on the JA2 network called for this type of open access. HIV in the United States. Regional Disparities in Qualified Health Plans’ Prior Authorization Requirements for Pre-Exposure Prophylaxis. They report finding significant regional differences in access to these drugs in the United States.

McManus and colleagues examined how 16,853 insurance plans managed payments for Truvada, a combination of two drugs, tenofovir disoproxil fumarate and emtricitabine. This  In 2012 the Food and Drug Administration approved Truvada for pre-exposure prophylaxis (PrEP) in combination with safe sex practices to reduce sexual risk in adults at high risk of HIV -acquired infection.

Examining insurance plans’ policies for 2019, McManus and colleagues found that 18.9% of health plans in the study required prior authorization for Truvada in the United States, but that rate varied by geographic region. are different. Looking at rates by region, they found prior authorization requirements for Truvada for 37.3% of plans in the South, 2.3% in the Northeast, 6.2% in the West and 13.3% of plans in the Midwest.

This disparity was especially true given the growing concern about HIV infection in the South, write McManus and colleagues. They note that the Centers for Disease Control and Prevention estimates a lifetime

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