Evidence-Based Medicine and Prior Authorization

“All the important things you want to do in life are made possible by pervasive trust.”

Fullinwider’s review of Sissela Bok’s Lying: Moral Choice in Private and Public Life (1978)

Payers developed prior authorization to ensure the appropriate medical resource utilization. Prior authorization is based on evidence-based criteria. A registered nurse employed by the health plan reviews each prior authorization request . If the nurse determines the prior authorization is not medically necessary, the nurse then asks a medical director to make the decision to reject the request. The member’s physician can appeal to the same medical director. In some cases, the member’s physician can ask for a physician within the request’s medical specialty to review the appeal. Requests can also be escalated to an external review organization to consider overturning the payer’s prior authorization denial.

Although some have suggested that prior authorization can support patient-centric care (e.g.one lipid clinic formalized its drug escalation pathway to match the published evidence and minimize prior authorization rejections for PCSK9 inhibitor agents), most providers find prior authorization to be burdensome at best and dangerous for patients at worst. In response to these administrative burdens, at least one study found providers over-reporting drug side effects  to help patients qualify for more expensive medications. A group of industry organizations including the American Hospital Association, America’s Health Insurance Plans, the Medical Group Management Association and the American Medical Association recently issued a consensus statement to improve the prior authorization process. Their recommendations include:

  • Selective Application of Prior Authorization
  • Prior Authorization Program Review and Volume Adjustment
  • Transparency and Communication Regarding Prior Authorization
  • Continuity of Patient Care
  • Automation to Improve Transparency and Efficiency

Fortunately, health information technology can address many of these recommendations. Prior authorization for pharmacy benefits has advanced further than prior authorization for medical benefits. On October 4, 2018, Congress passed the SUPPORT for Patients and Communities Act (HR6). Although the bill was primarily focused on opioid recovery and treatment, section 6062 called for electronic prior authorization (ePA) for Medicare Part D drugs using the National Council for Prescription Drug Programs (NCPDP) SCRIPT standard no later than January 1, 2021. NCPDP is moving one step further to develop a Real Time Benefit Check standard (patient’s benefit information and medication pay amount) that will operate between the Telecom (pharmacy drug claims and workflows) and SCRIPT (e-Prescribing and ePA workflows) standards in the hopes of advancing a task group by early 2019. The Real Time Benefit Check standard would need to cover all payers for maximum provider adoption.

Health Level Seven International (HL7) has outlined a similar process for helping providers determine the member’s medical benefit coverage requirements in real-time. The HL7 use case is focused on addressing the provider’s need to discover which payer covered services or devices have specific documentation requirements, rules for determining need for specific treatments/services and requirements for prior authorization or other approvals. HL7 expects a reference implementation by mid-2019 using CDS Hooks, a SMART (Substitutable Medical Apps, Reusable Technology) on FHIR (Fast Healthcare Interoperability Resource) technology. The PHI (Personal Health Information) version will allow the payor to determine/confirm which product is covering the patient and use information to refine the response. The group expects to explore prior authorization and pre-claim requirements, documentation templates, payor rule sets and guidance documents. Any HIPAA-covered ASC (Accredited Standards Committee) X12 transactions, interactions with any intermediary, asynchronous responses, access to a healthcare directory and authentication and authorization will be considered “out of scope.”

What might a health information technology-enabled prior authorization process look like that minimizes the friction for all stakeholders?

1. Longitudinal patient record that allows different entities to send health information as encounters occur to facilitate chart review and prior interventions

   a. Patient control over what records to share with specific healthcare providers, family members or research teams

   b. Track patient-oriented outcomes to monitor patients outside formal healthcare encounters (e.g., mental-status, functional status, condition-specific assessments)

   c. Stakeholders would subscribe to patient records after obtaining patient consent

2. Cross-payor access point within an office or hospital electronic medical record that leverages single-sign on and patient context to display patient- and payor-specific information to support a payor-customized experience. The access point could display

   a. Prior claims and associated health information (e.g., problem lists, medication lists, discharge summaries, imaging reports, pathology reports)

   b. Recent authorizations for the patient

   c. Ability to review orders for downstream payor management

        i. Medication, radiology and laboratory ordering conversations to display alternatives and co-payment information in real-time. Orders could be reviewed against evidence-based guidelines and checked for earlier medical interventions for electronically-driven prior authorizations that do not interrupt the provider or ask the provider’s back-office staff to upload supporting documentation. Orders could be directed to the highest-value pharmacy, radiology facility and laboratory, respectively. Radiology and laboratory results could route back to the ordering provider and tracked in the longitudinal health record.

     ii. Referral ordering conversations that could be evaluated for appropriateness and include suggestions for high-value providers. After the evaluation was completed, the information could be routed back to the ordering provider and tracked in the longitudinal health record.

3. Asynchronous communication to allow conversations to best meet each stakeholder’s work expectations rather than address patient tasks in real-time

The challenges in implementing these features are no longer technical. We will need associations to help mediate conversations among competitors to generate standards to share information. Each group of stakeholders will need to determine how they will create competitive advantages over this shared platform to help keep or grow market share. But the model suggests patients control their records and interactions are structured to optimize patient outcomes from a cost, satisfaction or other value metric.