On the hot stove that is the healthcare debate in America, prior authorization or pre-authorization, as it is sometimes called, is on the front burner.
What is Prior or Pre-Authorization?
Prior authorization is when a doctor or other healthcare provider, acting on behalf of a patient, requests approval or authorization from the health insurer before delivering a treatment or service. The health insurer then works with medical professionals (including pharmacists) to ensure access to safe and effective treatments so patients receive the quality care they need at a price they can afford.
If, for example, a family doctor wants to prescribe antibiotics to a patient with sinusitis, an insurer may need to authorize the treatment. If a doctor wants to send a patient with back pain for an MRI (magnetic resonance imaging), an insurer may need to approve the procedure.
Prior Authorization Improves Patient Care
Some physicians might regard prior authorization as a non-medical broomstick being thrust into the whirring spokes of doctor-patient relationship – an obstacle to good patient care.
In reality, prior authorization is a tool used by health plans like Capital BlueCross, and government-sponsored healthcare programs, to help ensure patients receive the right treatment based on well-established, scientific evidence of effectiveness and safety.
Prescribing antibiotics for sniffles, coughs and colds, or prescribing an MRI for non-specific back pain are two classic examples in which unnecessary or inappropriate treatment might occur.
In the first case, antibiotics treat bacterial infections but not viral infections.
So, as the Mayo Clinic points out, an antibiotic is an appropriate treatment for strep throat, which is caused by the bacterium Streptococcus pyogenes, but it is not the right treatment for a sore throat, a cold, bronchitis and coughs, most of which are caused by a virus.
And for the patient with back pain where there is no underlying medical condition or injury present, prescribing a costly MRI, or a powerful opioid medication, is not always the best option. The best course of action might well be over-the-counter, anti-inflammatory medications and physical therapy or exercise.
Prior Authorization Reduces Unnecessary Healthcare Costs
Wasteful, inappropriate medical spending is a big deal in healthcare.
A recent study in the Journal of the American Medical Association concluded that wasteful treatment is one of six factors contributing to an estimated $760 billion to $935 billion in wasted healthcare spending in the United States each year.
That’s about 25 percent of the roughly $3.5 trillion spent on healthcare annually in America.
Specifically, overtreatment or low-value care, accounts for an estimated $75.7 billion to $101.2 billion of that total, the JAMA study concluded.
Another medical study concluded that the fear of malpractice, patient pressure, and difficulty accessing medical records were the top drivers of overtreatment.
Prior Authorization Promotes Best Actual Treatments
Prior authorization helps address the large gaps that sometimes exist between the best actual treatments and the treatments that are often delivered. Prior authorization also helps prevent medical errors, including the underuse of effective care and the overuse of care that is unproven or known to be ineffective.
With prior authorization, health plans get input from medical professionals to set medical and pharmacy policies that are supported by scientific evidence. The process is a guardrail that helps guide medical professionals toward the best, most effective, often less costly treatments, and away from wasteful, less-effective, often exorbitantly-priced ones.
Prior authorization is critical to delivering patient-focused care and does not create inappropriate barriers to necessary services. Instead, prior authorization ensures services are being ordered in the best interest of – and with the knowledge of – the patient. Health plans are partnering with physicians, pharmacists, medical groups and hospitals to identify opportunities to improve the process.
The goal, as always, is to reduce spending on unnecessary care and ensure premiums are more affordable for all consumers.