Clear communication, as part of the doctor-patient relationship, is one of the most fundamental aspects of healthcare delivery. Patients need to understand the implications of procedures and medications, and they need to trust that their provider has their best intentions in mind.
Over the years, this dynamic has been negatively impacted by the widespread adoption of prior authorization (PA), a measure intended to address rising costs in healthcare by affording insurers the oversight to assess the appropriateness of a clinician’s care regimen—and to delay or decline payment if they dispute the necessity.
After decades of implementation, costs continue to grow, and the measure’s ability to impede treatment and procedures has resulted in a bureaucratic albatross, which runs contrary to the purpose of its creation. A 2024 survey conducted by the American Medical Association (AMA) found that PA alone encompasses 13 hours of work per week for physicians and staff. It also results in higher utilization of healthcare resources, including more high-cost forms of care, and greater out-of-pocket expenses for patients.
But the cost savings component is one slice of the story. Delays breed annoyance. Denials breed outrage. For an industry that is intrinsically tied to trust and care, this is a mechanism that has eroded both. Understandably, calls for the drastic overhaul of PA are gaining steam.
While cost impact is understandably a focal point, there is simultaneously an opportunity to improve the perception of the healthcare industry. Reforming PA presents a chance to reclaim the critical communication connection between patients and providers.
The introduction of PA was intended to address a growing problem: increased healthcare costs. PA’s creation coincided with a time when insurers wielded a significant amount of clout. That leverage enabled a cost-containment measure that served to improve their bottom lines and inserted them into conversations on patient care. By adding another voice, and one whose priorities were focused on cost, the process of care delivery slowed and became more frustrating for all involved.
Every step of the PA process inhibits the doctor-patient relationship. Paperwork and phone calls—sometimes multiple rounds—delay care. Patients are routinely left waiting, status unknown, creating annoyance with a system that is challenging to navigate. Whereas difficult health conversations are held directly with care providers, PA resolutions are delivered electronically, by mail, or through an intermediary. Frustratingly, in a 2023 report, the Massachusetts Health & Hospital Association found that 80% of initial denials are due to “administrative reasons, including prior authorization” and an equal amount are eventually overturned.
As annoyance mounts, the desire to engage with the healthcare system dissipates. For patients, it means failing to maintain regular checkups with clinicians. That same 2024 AMA survey found that 82% of respondents indicate that PA can “at least sometimes lead to treatment abandonment.” For clinicians, time spent on administrative tasks contributes to “moral injury.” It can result in burnout and desires to leave the job or the profession altogether.
Over the decades, personal interactions with PA—for patients and clinicians—have fueled greater animosity. For years, the response was limited to simply grinning and bearing it. But now, the winds are starting to blow in a new direction here in Massachusetts. Is PA needed? Is it helpful?
Earlier this year, David Rosenbloom penned an op-ed in The Boston Globe that referred to PA as a “scam.” While the sentiment was not necessarily novel, the messenger was striking. Not long after that piece’s publication, Michael T. Caljouw, the Massachusetts commissioner of insurance, vowed to a group of healthcare leaders that he was taking a hard look at the practice of PA. Rosenbloom was one of the architects of PA when it was conceived, and Caljouw is a lifelong insurance executive. To have these voices denouncing PA represents a tipping point. That adversarial clinician versus insurer dynamic has been replaced by a belief that the entire system would benefit from moving away from PA.
What would PA reform look like in practice? Going from full oversight to none is not in the cards. Although PA has been far from a success, the legitimate concerns around rising healthcare costs that prompted it still persist. Today, roughly 90% of PA is approved, which offers strong indication that review is too broad. Reviewable treatments that are seldom rejected should be omitted from PA. Those that remain would be those for which the practice was—in good faith—intended to examine. That is an outcome all parties can be satisfied with.
PA reform is unlikely to upend the mechanics of healthcare delivery, but it does have the potential to bring significant, positive changes to the way everyone interacts with it. Clinicians will have more time and bandwidth for patient care and communication with fewer administrative roadblocks. Patients will receive care quicker and with greater clarity. Reducing frustrations with the system portends sticking with it. PA reform is an opportunity for healthcare to recalibrate and reemphasize the human element and compassion that have dissipated through bureaucracy.
Rich Copp is an executive vice president leading the healthcare practice at Issues Management Group, an integrated strategic communication, public affairs and digital firm headquartered in Boston, Massachusetts.
Publisher: Source link
