Unbiased Analysis of Today's Healthcare Issues
That is the findings from a KFF Health Tracking Poll out this month. The survey examines which aspects of accessing care and health insurance are the biggest problem for insured adults. The survey finds that 69% of adults believe prior authorization is a burden. Specifically, the survey asks “When it comes to getting health care,…
Myself and Kristy Piccinini, PhD from FTI Consulting published a new commentary in The Evidence Base titled “Perspectives from the Healthcare Economist: Why CMS/AHIP’s prior authorization changes won’t hurt payers.” Dr. Shafrin and Dr. Piccinini share their insights in this Guest Column examining the implications of recent CMS/AHIP prior authorization reforms and why these changes are unlikely…
AHIP (formerly America’s Health Insurance Plans) released a statement yesterday saying that their health plan members “announced a series of commitments to streamline, simplify and reduce prior authorization.” 48 US health plans signed off on the statement. What were AHIP’s 6 commitments? Standardizing Electronic Prior Authorization. Participating health plans will work toward implementing common, transparent submissions…
A CMS proposed rule would expedite the prior authorization approval process. CMS summarizes key provisions of the rule as follows: Proposals include requiring implementation of a Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) standard Application Programming Interface (API) to support electronic prior authorization. They also include requirements for certain payers to include a specific reason…
Form Kaiser Health News: That’s why desperate patients like Nix — and even some physicians — say they have turned to publicly shaming insurance companies on social media to get tests, drugs, and treatments approved.“Unfortunately, this has become a routine practice for us to resort to if we don’t get any headway,” said Shehzad Saeed,…
Prior authorization policies may save money for payers, but they impose significant costs on patients and providers. A JAMA Viewpoint by Anderson, Darden and Jain (2022) examines various approaches for improving prior authorization in Medicare Advantage. In a recent survey of 1004 physicians, 88% reported that the burden associated with prior authorization requirements was high…
While many patients and physicians feel that it is increasingly difficult to get insurance to cover new treatments, a JAMA Viewpoint (Resneck 2020) demonstrates this trend numerically. Prior authorization requirements increased from 8% to approximately 24% of covered drugs on Medicare Part D plans between 2007 and 2019.1 In 4 therapeutic classes (including antidepressants, autoimmune disease…
Prior authorization is a requirement that health plans require physicians to obtain plan approval in order to prescribe a patient a given medication. Prior authorizations may be put in place to insure medications are not used inappropriately or for payers to try to reduce cost. While prior authorization may help save money, delays in the…
An interesting article by Cochran et al. (2017) examines whether health plan prior authorization rules can help prevent opioid abuse. The authors use Pennsylvania Medicaid data from 2010 to 2012. The data included both fee-for-service and managed care enrollees. The authors measured opioid abuse based on diagnosis codes for opioid use disorder (304.0, 304.00, 304.01,…
Prior authorization is a common tool that managed care organizations use to reduce patient utilization of medical services. Some physicians believe that prior authorization creates barriers to effective care, but other commentators believe that prior authorizations can be implemented in a more efficient manner. Either way, prior authorizations are a form of rationing care. Although…