Contributor: Transforming Prior Authorization to Facilitate Quality Care

Cathy Moffitt, MD, FAAP, CHIE, Aetna

Like many others, I was drawn to be a doctor because I wanted to help people. When I first started working in managed care, I told myself that I would leave if I ever felt I was not serving patients and upholding the same values that guided my time practicing pediatric and emergency medicine.

It’s been nearly 20 years, and I am still here.

Health plans have a responsibility to prioritize quality care and drive the best and most cost-effective health solution for each person, and utilization management helps us do so. I also know that industry-standard utilization management practices, like prior authorization, are not without administrative burdens, and they can bring frustration for providers if there are different perspectives on the best route for the patient. However, with the right processes and guidelines in place, prior authorization can help uphold safe, medically necessary care and prevent unnecessary services.

The impact of quality care

Prior authorization assesses the medical necessity of care for each person using evidence-based standards. A survey of 26 plans from America’s Health Insurance Plans revealed that the top two sources behind evidence-based guidelines for prior authorization programs are peer-reviewed studies (100%) and federal guidelines or studies (96%).¹

This focus on evidence-based care has real-life impacts. Though prior authorization is sometimes seen as an extra administrative step in the patient care process, this review is critical to helping members get the right care at the right time to support their health.

For example, one of our Aetna Medicare members recently developed excruciating nerve pain and immobility in her left arm. Her doctor recommended physical therapy, but she chose not to attend. An MRI revealed a chronic rotator cuff tear, and an orthopedic surgeon recommended physical therapy and a total shoulder replacement. The member again chose not to attend physical therapy, but asked to proceed with the shoulder replacement surgery.

The prior authorization of the surgery was denied because it revealed uncertainty about whether her shoulder pain was caused by a chronic rotator cuff tear or by residual shingles. After discussion with her clinical team, the member was willing to try physical therapy, which was paid for by her Aetna Medicare plan. Six weeks of physical therapy resolved the member’s pain, allowing her to avoid the cost of surgery and its respective 6- to 9-month recovery period.

Providers may sometimes worry that prior authorizations could lead to delays in care, but insurers can make sure that prior authorization is only requested for services and medications where it is needed.

In addition to upholding patient safety, prior authorization helps identify members for specialty programs, such as case management, disease management, and behavioral health services. These programs can help members proactively manage conditions before they turn severe.

Managing cost and quality

Although the reason for prior authorization is patient safety and health care quality, it also helps control health care costs for members and their employers. One JAMA study estimated that about one fourth of health care spending is on services that do not improve health outcomes for patients.² Prior authorization programs help reduce the use of unnecessary or potentially harmful care, as well as prevent members and employers from paying for higher-cost options when more affordable treatments are equally or more effective.

One of our members needed to receive regular immunoglobulin (antibody) infusions. Since they were getting the infusions at an outpatient hospital facility, they were required to pay 20% of the cost of the drug, resulting in nearly $300 out-of-pocket cost for each visit. During the prior authorization process, Aetna’s clinical team found that at-home infusion would reduce the member’s cost to just a $40 copay per infusion and make the treatment more convenient. A clinician then assisted the member in finding an infusion provider who could do the infusion in their home and for the lower cost share.

With national health expenditures expected to rise 5.4% through 2031,³ prior authorizations are a key mechanism to prioritize patient safety and health outcomes while simultaneously controlling costs for members.

Continuing to transform the practice

Over the past few years, health plans have been working diligently to simplify and expedite the prior authorization process and ease administrative burden on providers to enable them to focus their time on patient care. Health care plans should use analysis tools to identify providers that consistently deliver improved health outcomes, discerning when prior authorization is needed and most effective. In recent years, our Aetna team has refined and reduced prior authorization requirements for more than 1000 providers who consistently deliver high performance.

To avoid unnecessary delays in care, payers use digital tools and capabilities to make the process as efficient as possible for providers. Electronic Data Interchange transactions can make prior authorizations faster and more affordable by significantly decreasing the cost of prior authorization requests to providers, saving the medical industry around $450 million each year. Insurers can also use automation to facilitate timely reviews. However, these advancements should be carefully monitored to uphold evidence-based clinical standards. Aetna never automates medical necessity denials, ensuring each of those cases receives appropriate clinician review.

Combining innovation with diligent, evidence-based clinical review allows the process to be more efficient while maintaining the value of clinical assessment.

Bringing prior authorization into the future

As a health care executive, my aim is always to improve the experiences and health outcomes of our members while reducing financial and administrative burdens on our provider partners, patients and customers.

Health plan management is about improving people’s health and quality of life—the same mission I held when treating my own patients. Clinical quality and safety are core to our utilization management goals, and payers must continue to assess their prior authorization practices to uphold these goals.

References

1. 2022 Industry survey on prior authorization & gold carding. America's Health Insurance Plans. Accessed September 5, 2024. https://www.ahip.org/documents/2022-Prior-Auth-Survey-Results-FINAL.pdf

2. Shrank WH, Rogstad TL, Parekh N. Waste in the US health care system: estimated costs and potential for savings. JAMA. 2019;322(15):1501-1509. doi:10.1001/jama.2019.13978

3. Keehan SP, Fiore JA, Poisal JA, et al. National health expenditure projections, 2022-31: growth to stabilize once the COVID-19 public health emergency ends. Health Aff (Millwood). 2023;42(7):886-898. doi:10.1377/hlthaff.2023.00403

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