A new study published today in the issue of Journal of the American Medical Association (JAMA) analyzes the pros and cons of prior authorization (PA) policies for Medicare and the impact of these policies on patients and clinicians.
Specifically, the study examines health care delivery policy under Medicare Advantage (MA), which covers more than 48% of Medicare beneficiaries and may affect clinical operations.
There is currently a lot of talk about modernizing and controlling AP use in Medicare to better serve patients and the entire health care system. We hope that by describing the theoretical goals of prior authorization and where implementation falls short of those goals and the needs of Medicare beneficiaries, we can provide policymakers with a comprehensive account of the system and the possibilities to improve it. »
Kelly E. Anderson, PhD, MPP, Senior Author, Assistant Professor, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus.
The paper discusses the policy’s impact on numerous stakeholder groups, including patients, clinicians, MA insurers, and the Centers for Medicare and Medicaid Services.
Anderson and her co-authors argue that if PA policies are used effectively, they can be a powerful lever to improve the appropriateness of care, reduce overconsumption, and contain rising health care costs.
However, they point out that frequent misapplications of the PA process have resulted in serious harm to patients and unnecessary delays in care, which can prove costly in the medium to long term and undermine patient and provider confidence. clinicians in the process.
In addition, from the perspective of clinicians and health care centers, this policy represents a significant administrative burden and barriers to providing patient care. For example, clinicians worry that decisions critical to the health care of their patients are being made by clinicians who do not practice or who have inadequate clinical expertise in the specific clinical area.
To address these issues, the researchers propose several measures to improve PA utilization in Medicare. For example, the use of an electronic PA process with time requirements for initial and appeal decisions. As well as reporting AP denial rates to the Centers for Medicare and Services, to name a few.
The paper concludes that by improving the transparency and accountability of the PA process, the policy can work better as a tool to improve high-quality care for Medicare beneficiaries.
Source :
University of Colorado Anschutz
Journal reference:
Anderson, K.E., et al. (2022) Improving Prior Authorization in Medicare Advantage. JAMA. doi.org/10.1001/jama.2022.17732.