Many doctors believe that previous authorization impedes healthy patient care. New reforms from … more
You learn a lot in medical school. On human biology, medical ethics and the way of diagnosis. One thing they do not teach you – but which overturns his head all the time in the actual practice of medicine – is previous authorization.
The previous authorization is what is known in health care as a utilization tool. Doctors submit requests to insurers, who respond to whether they will cover the proposed procedures, services or medicines before the patient to receive them. The goal is to direct customers to care ways that have been shown to produce the best results at reasonable costs.
During office hours, between procedures, even in the middle of advice – Prior’s authorization is something that doctors have to constantly face.
Last week, amid control by legislators and regulators, as well as public anger for practice, health insurers working with the AHIP Trade Union (in the Board of Directors of which I am sitting as CEO of Scan Health Plan, a non -profit health insurance company) announced A set of voluntary commitments aimed at simplifying the previous authorization and “connecting patients faster with the care they need, while minimizing administrative weights to providers”. Commitments include faster recovery times, greater transparency and reduced requirements for ordinary approved services. These reforms are reasonable and – let’s be honest – probably delayed.
But will they make a difference?
‘Administrative Obstacles’
Despite its daily impact on medicine practice, previous authorization is not something that doctors speak very much. So, in order to measure how the previous authorization affects their work and their patients and what the result could have voluntary reforms, I have reached several colleagues in various specialties to hear their stories about the previous authorization. What I heard was honest reflections on their experience with practice – and an emergency call for a system that often impedes care.
Jay Patel, an orthopedic surgeon of the Orthopedic Institute in Orange County, Ca, describes a system that is increasingly delayed so that the reason is not clear, putting “administrative obstacles to surgeries that are appropriate”.
Patel notes that some payers demand that they submit representation reports to separate documents copying the information contained in medical records previously submitted. “Most of the time there is some small information that is already in the file and approve it reflexes.”
But not always. And when delays occur, he says, they disrupt care and reduce confidence between patients and their doctors. “Patients often do not understand how the process works,” he says. “They usually think we fall the ball because we are the person they can get.”
Patel believes that the system could improve by reducing previous authorization requirements for doctors who consistently provide proper care. “Good actors should be able to seek surgery and have approved her.”
‘Delayed matter’
An interventionist cardiologist in Northern California I know he sees firsthand how delays in care can lead to worse results. “For each test, you have to wait a week for authorization,” he says. “And when it comes to heart disease, matter is delayed.”
He is aware that delays can push patients to seek urgent care when experiencing shortness of breath or other symptoms. “Put yourself in their shoes. When your heart hurts, you may be afraid that you will die. ” He says that some of his patients have decided to go to the emergency room rather than waiting for approvals. In these cases, patients are accepted and treated as hospitalized, who notes that it is ultimately more expensive for the plan, the patient and the health system in general.
The cardiologist also notes that in his field, denials are rare. Although he often has to get the phone to support a patient, he says that in 11 years of practice, he never has a health plan to refuse a process he has requested.
Knowing this, he wonders whether artificial intelligence or other technologies could offer ways to improve the system. “There must be ways to optimize this. If they allow the procedure 99% of the time, why can there be no immediate authorization?”
International Jonathan Dinh, chief executive of Tri-Valley Medical Group/Guidant Health, says that insurers often use previous authorization as a “delay tactic”. He says that from his experience, some payers deliberately make the practical burden, knowing that some percentage of doctors will be disappointed and resigning from the time -consuming process of previous authorization. “If there is a bad clinical outcome, the health plan maintains reasonable mistrust. They will say,” we never said “no”. We left the decision strictly to our providers. ”
As the head of the Internist and the Medical Team, Dinh believes that the effectiveness of the previous authorization reflects the quality of the organization itself. “In a good group, 80% to 90% of applications should be automatic approved,” he explains. “The primary functioning of the previous authorization should be ensured that patients refer to the correct provider in the network, helping them avoid unnecessary medical accounts-not to act as an obstacle to care.”
Dinh says that transferred models to which payers are entrusted with certain administrative and clinical responsibilities – such as management management, care coordination, and previous authorization decisions – in a supply organization or medical team can reduce the friction of the previous authorization. However, he warns that this model is not enough alone. “Authorized entities can still be delayed or denying care.
Dinh also says that patients often accuse incorrect delays by seeing a specialist due to the previous authorization process when the real underlying issue is a lack of doctors. “People often blame delays seeing a specialist for the previous authorization process,” he says. “But in many cases, references are issued immediately – the actual congestion is a lack of doctors. Experts are overwhelmed and simply do not have the ability to see patients quickly.
To address the broader issue of doctors’ shortages, Dinh and his colleagues started a new Internal medicine program focusing on training more international primary care. The initiative aims to extend access to care and improve results, especially in inadequate communities. “A well -trained Internist can help offset the lack of experts by managing complex conditions at a high level.
A starting point
When a plan of AHIP’s plan first crossed my office, I was skeptical. Voluntary reform is not something that has a great history of health care. And even more than 50 plans (including my own) providing coverage to tens of millions of Americans have signed and made a public commitment to reform.
After talking to my colleagues doctor and listening to their serious frustrations, there is no doubt in my mind that the system needs the Union reform and suggestions – which are not unpredictable and will face many of the problems – is a great place to get started.
After all, none of the doctors I talked about to ask for a blank check. They ask for a system that trusts their judgment, respects their time and first puts patients. The reform of the previous authorization only concerns efficiency.
It is the dignity – the rejection of the people who take care and the people who need it – and the ahip plan, recognizing some of the challenges facing my colleagues every day is an important step in the right direction.
