It’s no surprise that stakeholders across the healthcare industry feel that the current approach to prior authorization is broken. With patients, doctors and health plans all feeling the friction of manual processes and delays in care, many are left asking “is there a better way?” Here at Cohere Health, we know there is and have partnered with the American Academy of Orthopaedic Surgeons (AAOS) to rethink the out-dated system. Both organizations are well-versed in the topic, with AAOS representing the forefront of clinical expertise in musculoskeletal care and Cohere providing cutting-edge technology with a focus on value-based care.
In our recent co-authored whitepaper, Reimagining Prior Authorization for Musculoskeletal Care, we provide insights around the need for change along with details on how we are working together to transform a historically burdensome process into one that enables better patient outcomes without delays. Below are three take-aways from that whitepaper.
A history of tension
To understand the need for change within the prior authorization process, it’s important to understand the current state of affairs. Prior authorization (PA) has become a major bone of contention between providers and health plans, with the patient often stuck in the middle. Physicians often see these PA requirements as a micromanagement by the health plan typically driven by financial factors rather than the best interest of the patient. A 2020 survey of physicians conducted by the American Medical Association paints a picture of the current situation in more detail with 85% of respondents describing the burden associated with PA as high or extremely high and 94% reporting care delays due to prior authorization requirements.
Administrative burden is not the only cause for frustration with physicians. The historical use of outdated technology without industry standardization has added to the challenge of leveraging modern-day technology to help streamline the process. These issues, combined with siloed decision making, and peer-to-peer reviews by non-speciality physicians, shine a light on the ample opportunity to create a system that works positively for all involved.
Rewarding high-value care
There are many opportunities to relieve some of the administrative burden from physicians within the prior authorization process, including rewarding high-quality care. One approach that has recently gained momentum is “gold carding” which allows physicians with a track record of high approval rates to be exempt from PA requirements for certain services. While removing PA in this way is headed in the right direction, our organizations believe that implementing a “green lighting” approach provides a more appropriate reward system. Gold carding is typically based on a static decision based on a moment-in-time with little ability for changes, while green lighting includes real-time data capabilities that track changes along with considerations for downstream clinical outcomes, and can help strike a better balance between administrative burden and clinically appropriate care. Currently, AAOS and Cohere are testing a program in which American Joint Replacement Registry (AJRR) participants can qualify for green lighting in hopes of building on the opportunity to further support the mission of transforming UM.
Centering care around the patient through a unique care path approach
Instead of keeping the current one-size-fits-all approach, our organizations are committed to creating the next generation of PA, and that starts with leveraging clinical intelligence and technology. Technology challenges of the past are slowly dissolving due to policy and regulations dealing with interoperability. These industry policies will standardize the format for how data is made available, making it easier to leverage technology within the process. With these steps in place, it is possible to understand and make decisions based on the patients longitudinal care journey allowing the PA process to reorient around a care path based on a diagnosis instead of an individual service request. This type of transformation is better aligned with how physicians think and how patients actually experience health care. Because of our partnership, AAOS Clinical Practice Guidelines have been integrated into Cohere’s care paths which has created a platform that is driven by the latest clinical evidence and expertise. Thus far, we’ve seen numerous benefits to all stakeholders involved in the process, including:
- 38% reduction in provider time spent on authorizations
- 65% of requests using a care path
- 92% satisfaction rate from physicians
- 4 days faster to care for patients
The future is bright
While the AAOS and Cohere continue to partner and see positive results, it remains clear that only a new way of thinking is going to help transform prior authorizations and utilization management. Learn more about how we’re tackling this issue together by downloading the complete whitepaper here.
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About the Author: Cohere Health
