If We End Prior Authorization, What Could Be a Better Future?
End Prior Authorization
Imagine that your doctor recommends cancer treatment and places an order for the services you need. Within a minute this order matches clinical care standards to existing documentation within your health record. You and your doctor are informed that the services meet care standards and are given an estimate of your costs. The health plan has no authority to override the clinical standard or deny coverage if conditions specified in the clinical standard are met. This course of care and supporting data are sent electronically to your insurer. They have a minute to respond electronically to say how much they will pay for the service and what your copay will be. You leave your doctor’s office knowing you will get timely care and what it will cost you.
This future is in stark contrast with the current process where health insurers request all documentation upfront, have complete liberty to decide coverage or deny it completely, and even after approving the service have denied the service after the fact. Eliminating PA can speed clinical services, reduce patient harm, save our economy tens of billions of dollars (See Study Magnitude and Effects Of Sludge in Benefits Administration: How Health Insurance Hassles Burden Workers and Cost Employer) , and reduce a significant waste of patient, employer, and clinician time and anxiety.
The current conflict of interest, that it is cheaper for a health plan to deny or delay care, potentially letting someone die, goes away and the insurer returns to being the insurer, not the judge and jury. Without barriers imposed by PA, patients and doctors are empowered to participate in shared decision making and pursue optimal health. This future will need a coordinated effort by the public, health care professionals, IT system vendors, regulators and lawmakers.
Eliminating prior authorization: A call to action
If you are a patient, family member, or physician who has been impacted by PA or another health plan denial process, this is a call to action. You do not have to accept this harmful practice as business as usual. If you would like to get more information about why ending PA must be a priority, join our newsletter. We welcome everyone with an interest in addressing root causes of patient harm and clinician burnout, especially PA. Your voice is important. Contact your elected representatives to tell them that this stain on healthcare in the US can be replaced by a fair, fast, economical, and clinically driven process that will save lives.
About Dr. Larry Ozeran
Dr. Larry Ozeran has more than 20 years of experience with information technology and software development, clinical medicine, healthcare leadership, and health policy. His efforts have ranged from the development and interpretation of public policy to supporting startups develop market strategy to outreach and education for clinicians, clinical workflow assessment, and evaluation of technology for healthcare organizations.
Dr. Ozeran has responded to proposed federal regulations, written to many elected officials, and testified before committees of the State Senate and Assembly. He was an invited speaker before the Congressional Budget Office. He has focused on strategic initiatives, policy development, and innovation supporting healthcare entities, government agencies, and startup companies.
