Coronary artery disease (CAD) is the leading cause of mortality for patients with diabetes, and its impact is only growing. With intelligent prior authorization (PA), healthcare organizations can reduce care variation, promote evidence-based care, and drive better outcomes for patients with cardiovascular conditions. This cutting-edge technology allows for more effective interventions, helping healthcare providers address these challenges head-on.
Understanding the link between diabetes and CAD
Diabetes significantly increases the risk of CAD, making it two to four times more likely in diabetic patients. CAD is the leading cause of death in this group, contributing to the rising rates of heart disease-related mortality post-COVID-19. The death rate from heart disease reversed its decline, rising 4% from 2019 to 2020, wiping out five years of progress.
Given this backdrop, leveraging PA can significantly improve patient care and reduce healthcare costs. By automating and streamlining the prior authorization process, health plans can significantly improve care coordination, reduce unnecessary tests, and improve patient outcomes.
How intelligent PA improves care for cardiology patients
Intelligent PA solutions integrate real-time patient data into the approval process, allowing for evidence-based decision-making before authorizations. This technology minimizes variation in care, aligns healthcare providers with best practices, and helps improve patient outcomes.
Health plans can use PA to identify opportunities to reduce unnecessary and costly procedures. For example, providers often overuse myocardial perfusion imaging (MPI-SPECT), even though it is most effective only for symptomatic patients with an intermediate likelihood of CAD. Prior authorization can help steer providers toward more cost-effective, noninvasive tests like coronary artery calcium scoring or exercise treadmill tests, significantly reducing costs while ensuring appropriate care.
Cohere identified this expensive and sometimes unnecessary test as a perfect opportunity to leverage technology to align providers on appropriate high-value care. Using the pre-test probability risk chart below, Cohere deploys behavioral change notifications at the point of the service request, such as “nudging” providers to consider an alternative, lower-cost, less invasive test where appropriate, such as a coronary artery calcium score, routine exercise treadmill, CCTA or a stress echo.
Encouraging evidence-based medicine: Risk-stratifying CAD
One condition that intelligent prior authorization has been focusing on is coronary artery disease (CAD), the leading cause of death in the United States. With the United States spending $320 billion annually in 2016 managing and treating CAD and cardiovascular risk factors (cardiovascular spending), Cohere is targeting this population to encourage high-value care pathways and reduce total spending.
According to evidence-based research conducted by cardiology societies such as the American Association of Cardiology, myocardial perfusion imaging (MPI-SPECT) is most useful in symptomatic patients with an intermediate likelihood of angiographically significant CAD. Cohere identified this expensive and sometimes unnecessary test as a perfect opportunity to leverage technology to align providers on appropriate high-value care. Using the pre-test probability risk chart below, Cohere deploys behavioral change notifications at the point of the service request, such as “nudging” providers to consider an alternative, lower-cost, less invasive test where appropriate, such as a coronary artery calcium score, routine exercise treadmill, CCTA or a stress echo.
Table 5 Pre-test probabilities of obstructive coronary artery disease in 15 815 symptomatic patients according to age, sex, and the nature of symptoms in a pooled analysis of contemporary data
CAD = coronary artery disease; PTP = pre-test probability
In addition to the classic Diamond and Forrester classes, patients with dyspnoea only or dyspnoea as the primary symptom are included. The regions shaded light pink denote the groups in which non-invasive testing is most beneficial (PTP >15%). The areas shaded beige denote the groups with PTPs of CAD between 5-15%, in which testing for diagnosis may be considered after assessing the overall clinical likelihood based on the modifiers of PTPs presented.
Only intermediate or high-risk patients require advanced imaging, such as an MPI-SPECT test. Thus, health plans can reduce this population’s total cost of care and collaborate with physicians to encourage evidence-based medicine, reducing variation.
Mining data for proactive care
To better manage cardiology patients, PA solutions help health plans address whole-patient factors like smoking, poor diet, and lack of exercise. Evidence shows that tackling these issues can significantly lower the risk of CAD and other cardiovascular complications.
When providers submit authorization requests for cardiac interventions, our intake solution uses optical character recognition (OCR) and machine learning to scan clinical attachments and match patients with similar clinical profiles from our patient cohort database. The system identifies opportunities to enhance patient care based on evidence-based guidelines, such as recommending enrollment in a health plan’s care management program.
PA technology can also nudge providers to integrate lifestyle interventions into care plans. For example, during PA reviews, the system can suggest enrolling patients in smoking cessation or nutrition programs to support better cardiovascular health and outcomes.
Bundled authorizations for better outcomes
Another innovative feature of PA is the ability to bundle episodic authorizations. By combining cardiac rehabilitation and coronary intervention authorizations, health plans can encourage providers to follow clinical pathways that lead to better long-term outcomes. This approach helps reduce complications and lowers the overall cost of care.
Cohere’s impact on cardiovascular care
Our platform supports over 8,400 unique cardiology ordering NPIs and processes over 2 million authorizations annually. With a 95% platform adoption rate, we’re helping health plans streamline prior authorizations, reduce care variation, and improve patient outcomes.
Here’s a look at some of the key results:
- 95% platform adoption rate
- 5 days faster access to care
- 89% provider satisfaction rate
Experience how our advanced PA solution, Cohere Complete™, improves outcomes and reduces cardiology patient costs. Schedule a demo today to see it in action!
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About the Author: Cohere Health
