Prior authorization has ramifications for patients and physicians, but artificial intelligence (AI) has the potential to simplify the process, health policy experts said Thursday during an online panel discussion hosted by the Kaiser Family Foundation.
Recently there has been a growing backlash against prior authorization requirements. “Even when appropriate, prior authorization creates delays in care, and it can. [worsen] outcomes, and can affect things like cancer survival,” said Fumiko Chino, MD, a radiation oncologist at Memorial Sloan Kettering Cancer Center in New York City.
According to a 2023 survey by the American Medical Association, one in three physicians blamed the practice for serious adverse events, such as hospitalization, permanent impairment, or even death. Even just a day’s delay can potentially cause uncontrollable pain for the patient, Chino said. For cervical cancer patients, each day of delay “corresponds to a 1 percent reduction in local control rate,” he said. “If you have a 5-day delay, that’s a 5 percent reduction in local control rates.”
Delaying care can also have financial costs, said Anna Schwamlin Howard, JD, principal of policy development at the American Cancer Society Cancer Action Network (ACS/CAN) in Washington, DC. A patient waiting for pain medication to be approved could end up in the emergency room, driving up costs for both the patient and the payer, which Howard argued is “penny wise and pound foolish.”
But Trian Brennan, MD, a former CVSCare executive and an adjunct professor at the Harvard TH Chan School of Public Health in Boston, defended the practice, saying it reduces unnecessary care. About 15% to 30% of all care in the U.S. health care system is ineffective, Brennan said.
Besides, “there really aren’t any good studies … showing actual harm,” he argued. “There are a lot of surveys from doctors, in particular, that say there’s a lot of delay, but obviously there’s a response bias with that.”
Also, prior authorization is “pretty much regulated,” Brennan added. If private health plans don’t meet certain requirements — 7 days for a decision on standard applications, and 14 days for expedited — they are fined by the Centers for Medicare and Medicaid Services (CMS) or the Department of Labor. can be done
Estimating the cost to both the provider and the insurer, the return on investment of such policies is about 10 to 1, he said. “Does this sound like a reasonable thing to insure? [company] To continue to? It does,” he said.
However, due to criticism from lawmakers, patients and physicians, he is seeing a “pull back from utilization management” — another term for prior authorization — in cases where there is not a consistent return on investment, and A sharper focus on more “non-controversial” requests, Brennan said.
In January, CMS issued a final rule aimed at streamlining the prior authorization process for Medicare Advantage plans, state Medicaid and Children’s Health Insurance Program (CHIP) fee-for-service programs, Medicaid managed care plans. , and CHIP managed care facilities are included. File prior authorization decisions within 72 hours for expedited applications and within 7 calendar days for standard applications. The rule also mandates that insurers must publicly report their prior authorization measurements. Prescription drugs are excluded from the rule.
Howard, speaking for ACS/CAN, said his organization “would like to see those timelines expedited” to 72 hours for non-expedited applications, and 24 hours for expedited applications.
Brennan added that “the whole process could be completely automated” through computer programs that would take a prior authorization request and “basically interrogate the electronic medical record and come back with a decision immediately.” Will.”
He noted that at dozens of points during the final rule, CMS called on the Office of the National Coordinator for Health Information Technology (ONC) to “do its part” for changes to the electronic medical record.
Asked whether AI could improve prior authorization and prevent delays, the panelists were cautiously optimistic. “I wouldn’t be afraid of it, sort of The previousbut you want to make sure you’ve got full transparency,” Brennan said, adding that these decisions ultimately come down to conversations between physicians like Chino and other radiation oncologists. (Minnesota by two families who claimed an insurer used a flawed AI algorithm to deny essential care to their deceased elderly family members.)
Chino said he welcomed AI with “some caveats,” noting that disadvantaged populations are more likely to be “missing important elements” in their electronic medical records. “And then you’ve trained a machine based on a data set that’s essentially racist.” In an email to MedPage TodayChino explained that an AI prior authorization system could “inadvertently flag denial charts” based on “inaccurate datasets” that could then determine whether “other patients” — including high Income and coded as white — are “low risk, and speed up those approvals.
“So if one group gets approval faster, it can perpetuate inequality and disparate care,” he said.