Prior authorization has been round for a very long time. Initially designed within the Nineteen Sixties as a mechanism to manage prices and make sure the applicable use of medical sources, the aim has (in principle) been to stop pointless procedures and curb wasteful spending. However the actuality is that prior authorization has developed into an administrative quagmire that delays care and frustrates physicians. One survey discovered that 94% of physicians consider prior authorization results in delays in care, whereas 89% say it has a detrimental impression on scientific outcomes.
The easy fact is that the fashionable type of prior authorization is a barrier to effectivity and to optimizing high quality of care – and our business faces an ethical crucial to repair it. Nobody physique can do it alone. It has develop into more and more clear that prior authorization reform is a collective duty, requiring assist from private and non-private entities throughout the healthcare ecosystem.
An untenable administrative burden
Insurers initially applied prior authorization as a gatekeeping device within the face of an explosion of medical developments, new therapies, and growing prices. Over time, PA has expanded throughout almost each side of affected person care – drugs, diagnostic imaging, surgical procedures, and inexplicably, even to routine therapies. This has created an infinite administrative burden. In accordance with a current report from the Council for Inexpensive High quality Healthcare, the healthcare business spent $1.3 billion on administrative prices associated to PA in 2023.
It has develop into untenable. Physicians now spend a median of 13 hours per week navigating PA hurdles. That is time that medical doctors might be utilizing to deal with sufferers, however as a substitute they’re caught coping with pink tape. And whereas PA was designed by insurers to scale back prices, how has that labored out? Administrative waste has been one in all many components driving up healthcare spending, together with the downstream prices of untreated or poorly managed situations. This stopped being an inconvenience a very long time in the past: it’s graduated to a public well being disaster fueled by systemic friction. Reform is crucial—however how we pursue reform will decide whether or not we repair the issue or just add new layers of complexity.
A roadmap for accountable reform: Shifting past the established order
To deal with the prior authorization disaster successfully, we’d like a complete strategy that balances legit value issues with affected person care and supplier effectivity. I suggest a four-part roadmap to rework prior authorization. It gained’t resolve each drawback with right this moment’s PA processes, however on the very least it’s going to get us shifting in the correct path.
Step one is bettering transparency in prior authorization guidelines and metrics. Present PA standards are typically opaque, inconsistent, and tough for suppliers to navigate. Payers ought to be required to publish clear, standardized medical necessity tips, up to date month-to-month, so sufferers and suppliers know precisely what’s required. Guesswork is the enemy of effectivity.
Moreover, a public payer scorecard ought to be launched every month, displaying submission approval charges, turnaround occasions and overturn charges on enchantment. Knowledge should even be made obtainable through open APIs as a way to guarantee seamless integration into supplier workflows and decrease administrative burdens. Some progress is being made within the business: the Facilities for Medicare & Medicaid Providers handed a closing rule on streamlining prior authorization processes in 2024, however non-public business leaders should now step up with their very own reforms. They should be held to the identical normal, constructing on the prevailing CMS framework.
The second step is to remove gold-carding. I perceive the enchantment of exempting trusted events with good observe data from PA necessities. On its floor, gold-carding appears like an excellent resolution. The logic tracks. However this observe opens up a completely new can of worms, forcing suppliers to maintain observe of various guidelines for various insurers. By creating one other layer of complexity, gold-carding truly undermines the aim of lowering administrative friction and perpetuates a fragmented strategy. Quite than selecting and selecting which suppliers are exempt primarily based on standards decided by insurance coverage suppliers, payers want to come back collectively to create and undertake common insurance policies and requirements that apply to all suppliers, with an emphasis on truthful and clear guidelines. The best strategy to remove gold-carding is to render it out of date.
Subsequent up is regulation reform. The present established order is a multitude, with a patchwork of regulation that change from state to state. That’s obtained to go – we have to change state-level rules with a uniform federal coverage that applies to all. When you don’t consider me, simply go ask somebody working in compliance for a nationwide well being system or insurer: prior authorization rules are a nightmare stuffed with pink tape and conflicting necessities. It’s slowing us down and affecting the standard of care sufferers obtain.
Will or not it’s straightforward to create a single, federal normal that ensures transparency, timeliness and affected person security? You may choose up any newspaper and prepared concerning the dysfunction in Congress to reply that query. It’ll take actual effort, however this is a matter that has garnered bipartisan assist and the top end result will probably be price it: simplified operations, decrease compliance prices, and most significantly, guaranteeing that sufferers obtain constant remedy – no matter the place they dwell.
The ultimate step: we should carry physicians into the loop via technological integration. Interoperability throughout digital medical data (EMRs) is a foundational requirement for efficient PA, however presently inadequate. API entry have to be free and common to make sure all suppliers can combine prior authorization information straight into their workflows to scale back friction. As an added bonus, this permits physicians to give attention to affected person care moderately than paperwork.
Prior authorization reform is not an summary coverage debate; it’s a necessity for affected person security, doctor well-being, and system-wide effectivity. We can not afford to attend for an ideal resolution. The instruments exist right this moment to considerably scale back PA’s burden on our healthcare system, we simply must mobilize and implement them.
Collective will must kick in: it’s time for physicians, insurers and policymakers to cease tolerating the issue and begin fixing it. Our sufferers, and our healthcare workforce, have been ready patiently for an answer, however their tolerance is sporting skinny and so they deserve higher. The time to behave is now.
Photograph: sqback, Getty Photographs
Dr. Jeremy Friese is a transformative power on the intersection of healthcare supply, AI innovation, and payer technique. Because the Founder, Chairman, and CEO of Humata Well being, he leads the event of superior AI options that streamline prior authorization — addressing one in all healthcare’s most difficult friction factors for suppliers, payers, and sufferers alike.
Previous to Humata Well being, Jeremy pioneered AI-driven options for well being techniques and well being plans. His newest enterprise was acquired by Availity and serves because the spine for his or her prior authorization automation platform. Throughout almost 20 years at Mayo Clinic as each a working towards Interventional Radiologist and Govt Finance and International Enterprise Improvement chief, Dr. Friese drove strategic partnerships that expanded Mayo’s progressive care fashions to serve over 20 million sufferers worldwide. His expertise bridging scientific excellence with operational effectivity informs his strategy to healthcare transformation.
This put up seems via the MedCity Influencers program. Anybody can publish their perspective on enterprise and innovation in healthcare on MedCity Information via MedCity Influencers. Click on right here to learn how.
