Earlier this month, Michigan became the latest state to pass legislation targeting reforms to the prior authorization (PA) process. Like similar legislation being passed or proposed across the country, Senate Bill 247, aims to respond to the growing concerns raised by physicians, patients, and advocacy groups over the unnecessary burden and patient safety risk associated with legacy PA programs and processes.
In a 2021 survey of physicians conducted by the American Medical Association (AMA)
- 93% of physicians reported care delays associated with PA
- 34% of physicians reported that PA has led to a serious adverse event of a patient in their care
- 88% of physicians described the burden of PA as high or extremely high
So how does the Michigan bill aim to tackle some of these issues and how can health plans adequately prepare to meet the new requirements?
Like many states Michigan is driving the shift to digital prior authorization
The physician burden associated with PA is largely attributed to what is still a highly manual, labor intensive process. The AMA notes that 40% of physicians have staff who work exclusively on prior authorizations. To help alleviate this burden and expedite patient access to care, Michigan’s new bill requires that health insurers make a standardized electronic PA transaction process available by June 1, 2023, “utilizing an internet webpage, internet webpage portal, or similar electronic, internet, and web-based system.”
Timely patient access is critical
According to the Health Can’t Wait Coalition of Michigan, 94% of Michigan physicians report that “prior authorization redtape causes delays in care for their patients”. Consequently, due to the efforts of Health Can’t Wait and others, ensuring timely patient access is a central tenet of the new Michigan bill. Beginning June 1, 2023, PA for urgent requests will be considered granted if the health insurer fails to act within 72 hours of the initial submission. For non-urgent requests, this period extends to 9 days, again upon failure of the insurer to act. After May 31, 2024, a PA request is considered granted if the insurer fails to act within 7 days of the original submission.
Insurers will be required to adopt a program that modifies PA requirements for high performing physicians
Similar to the “physician gold carding” legislation recently passed in Texas, the new Michigan bill also requires health plans to adopt a program that modifies PA requirements based on the performance of health care providers with respect to adherence to nationally recognized evidence-based medical guidelines and/or other quality-related criteria. This regulation is specifically designed to not only support the broader issue of patient access but also the provider experience as well, reducing friction with providers who are proven to consistently deliver high value care.
So how can health plans adequately prepare?
The time for band-aid fixes to utilization management has passed. While legislation like that seen in Michigan and other states is well intentioned, and functioning as a necessary catalyst for change, forward thinking health plans recognize that simply digitizing or accelerating broken processes does very little to fix the underlying challenges these processes create for physicians and patients. The current legislative environment is an opportunity for health plans to embrace an opportunity to transform legacy utilization management programs from inefficient burdens into strategic assets, creating a reimagined approach that benefits all stakeholders and ensures optimal patient outcomes.
Cohere Health’s intelligent UM collaboration platform is designed to transform in-house or fully-delegated programs through technology, clinical intelligence, analytics and design to improve patient access, reduce provider burden and enable greater collaboration between health plans, providers and patients. It is the only UM platform designed to support the entire patient journey, not just individual transactions, and offers a series of truly unique features and functionality that not only meet, but exceed many of the goals established by Michigan’s legislature.
- Intelligent patient and provider-specific decisioning enables real-time determinations for faster turnaround times than those required in the Michigan legislation. Our solution’s advanced ML-driven technology and clinical analytics capabilities, combined with nationally respected, evidence-based clinical expertise, drives precision decisioning capabilities and an industry-best instant determination rate for appropriate care. 87% of authorization requests receive either an immediate approval or an immediate notification that the request will require manual review.
- Clinical analytics provide visibility into the patient population and physician behavior for faster, actionable insights to drive appropriate medical expense reduction and remove unnecessary provider friction. For example, in regards to Michigan’s bill, Cohere leverages a data-driven approach called “green lighting,” a next-generation approach to similarly proposed “gold carding” legislation, that removes unnecessary barriers for high performing providers who frequently demonstrate adherence to evidence-based best practices and other quality measures.
- Patient-specific care path recommendations, built by and for physicians and developed in partnership with industry leading organizations such as the AAOS and the American College of Cardiology, enable the authorization of the entire care episode, rather than a series of individual transactions, accelerating patient access and ensuring optimal outcomes.
- Proactive moments of influence upstream, such as in-workflow clinical suggestions, or “nudges,” offer real-time guidance to patient-specific, clinically optimal care choices at the point of diagnosis; creating much desired transparency around health plan policy and greater collaboration opportunities between the health plan and the provider.
The result of our differentiated approach?
- 96% physician adoption rate of our digital provider app
- 70% faster patient access to necessary care
- A Provider NPS score of 55
- 15% medical expense savings beyond incumbent programs
Ready to learn more? Contact us today.
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About the Author: Cohere Health
