Nearly three quarters of physicians (74%) report that prior authorization denials or delayed approvals led to patients abandoning their treatment plans. So it comes as no surprise that health plans are actively looking for a solution that will help them approve appropriate, quality care in a timely manner.
Automated prior authorization solutions can help improve turnaround times, but there’s a more comprehensive solution: intelligent prior authorization. It works by applying machine learning and artificial intelligence (AI) to suggest bundled requests, called episodic authorizations.
Episodic authorizations consolidate multiple related services triggered by a single high-profile event and occurring during a discrete care episode. By requiring a single authorization for multiple related services, health plans reduce the administrative burden associated with separate requests for this collection of services, and tighten the care episode for the patient.
The authorization request becomes a moment of influence for health plans with their physician partners. It is an optimization opportunity to reduce variation and align multiple coordinating providers on a discrete, evidence-based care pathway.
The result?
- An enhanced experience for providers
- Improved cost efficiency for health plans
- Better outcomes for patients
But if episodic authorizations can deliver these great results, why aren’t more health plans taking advantage of this new strategy?
Care management for many specialties is currently too siloed and difficult to coordinate. For plans to effectively form episodic authorizations, health plans (or their vendor partners) need to be managing care across a variety of specialties for it to have enough data and control to make an impact.
Health plans must also feel confident taking the lead in educating on medical necessity and recent specialty guidelines and improve interoperability between coordinating providers. To get there, effective programs must utilize administrative data and apply AI and machine learning to develop patient cohorts and construct evidence-based care pathways in order to isolate care episodes. They must make the recommendations available to providers in a way that is helpful and natural to their workflows.
If it all feels too futuristic, unpack how Cohere Health is already deploying episodic authorizations to improve musculoskeletal (MSK) care management. Similar to our care pathways, episodic authorizations support value-based care models. Episodic authorizations reduce duplicative services, facilitate proactive care management, and address inappropriate variations of care.
Here are seven things you need to know about episodic authorizations:
1. Episodic authorizations reduce variations and improve delays in care. This is extremely important in the musculoskeletal space because variations and delays in care contribute to:
- Health inequities
- Wasted cost
- Poor quality of care and reduced health outcomes
- Increased mortality and morbidity rates
- Prolonged pain
- Complications that may lead to additional surgery
- Exacerbation of injury or condition, leading to more aggressive and costly treatments
- Limited surgical options and decreased surgical success rates, since the condition is likely to deteriorate over time
2. Episodic authorizations are informed by matching patient profiling with patient cohorting data. Understanding this contextual information about the patient and how it maps to outcomes of patient cohorts with similar conditions empowers providers to prescribe better care for their patients. For example, if a patient is a candidate for a total knee replacement, but their body mass index (BMI) is over 40, we can use nudging to inform the requesting provider that patients with a similar profile have improved outcomes when also enrolled in a weight loss program. Applying the concept of episodic authorizations to this insight, the combination of programs can be treated as a suggested care episode and prior authorization could be bundled. A patient automatically enrolled in a weight loss program that has been preselected for them eases their access to care and optimizes their outcome post-procedure..
3. Episodic authorizations provide a comprehensive overview of a patient’s care journey. This provides an opportunity to identify patterns of low-value care, educate providers, and suggest higher-value alternatives. For example, according to care guidelines, patients should only have four pain management injections over the course of the year and so a care episode would only include four injections. By grouping the services into one authorization, the provider and health plan are alerted that if a patient requires more than the recommended injections per year, this may not be the most suitable treatment for their condition.
4. The care management and treatment of back pain is a key area of impact for episodic authorizations. Care management of back pain is costly for health plans, is cumbersome for providers, and is poor in quality for patients. Care pathways are long and often result in undesirable chronic narcotic use. With episodic authorizations, health plans can influence and manage care further upstream. Intelligent prior authorization solutions can utilize administrative data to identify patient cohorts and recommend episodic authorizations that will recommend treatment from high-value care providers earlier in the patient’s care journey and improve outcomes for the patient.
5. Episodic authorizations can be used to optimize a patient’s condition pre-surgery. Applying insights from patient cohorting data, providers can activate a care episode more likely to prevent the need for surgical intervention at all. For example, patients that are at high risk of developing osteoporosis are often not risk-stratified or screened properly. Episodic authorizations can be used to educate primary care physicians (PCP) on early indicators of osteoporosis, obtain an upstream diagnosis, and take preventative measures to reduce the risk of fractures and decrease the need for future surgical intervention.
6. Episodic authorizations benefit providers and health plans. Because episodic authorizations reduce the administrative burden associated with prior authorization, both provider groups submitting authorizations and the health plans benefit. Episodic authorizations are especially suited to providers who follow a predictable care journey for their patients, like for a total shoulder or knee arthroscopy. Episodic authorizations represent an impact opportunity to improve appropriate care management.
7. Health plans that choose to implement intelligent prior authorization solutions with episodic authorizations can anticipate costs and manage care more effectively. Ensuring that a surgery patient can begin physical therapy within 48 hours of their procedure, driving better outcomes and less complications, is just one example!
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About the Author: Traci Granston M.D.
