Dr Ken Cohen Discusses the Role of Prior Authorizations in Value-Based Care

Ken Cohen, MD, director of translational research for Optum Care, talks about the value of prior authorizations in different contexts, and how simplicity can benefit the process in some situations.

Transcript

Prior authorization is a large point of contention between payers and providers. What role does better use of data and evidence play in addressing prior authorization concerns from clinicians?

It's an important question, and clinicians are understandably abraded by a prior auth. It is not a pleasant part of anyone's day, and there are a few things that you can do. For example, you can use an [natural language processing] engine to read colonoscopy pathology reports and know when somebody is due for colonoscopy. That process could be completely automated so that the colonoscopy can be auto-authed and never undergo a formal prior auth process.

There are times when you can look at the high-value, low-value care of any given specialist and actually give them a green light. If they have demonstrated compliance with best evidence-based medicine, you can just remove the prior auth from that physician entirely, and you can do retrospective reviews. So, there are ways that you can make it much, much simpler.

On the other hand, there are times when prior auth still has a role. For example, if a physician is routinely prescribing an expensive brand name biologic rather than a biosimilar, and the reason is that the revenue is higher on the brand name, that's an area where prior auth has value. I think you have to look carefully at the situation, automate where you can, greenlight where you can, and apply prior auth where outcomes aren't impacted, but costs can clearly be reduced.