Overcoming Prior Authorization Challenges with Technology

The latest survey from the American Medical Association (AMA) reveals the significant challenges posed by prior authorization in healthcare. Prior authorization, a process insurers use to manage healthcare utilization and control costs, often disrupts patient care, burdens physicians with administrative tasks, and wastes healthcare resources.

The Consequences of Prior Authorization

Conducted in December 2023, the AMA survey paints a stark picture of the impact of prior authorization:

• Patient Harm: Nearly one in four physicians (24%) reported that prior authorization has led to serious adverse events, including hospitalization, permanent impairment, or death. Furthermore, 93% of physicians observed a negative impact on clinical outcomes, and 94% noted delays in accessing necessary care, often causing patients to abandon their treatment due to struggles with health insurers.
• Administrative Burdens: Physicians complete an average of 43 prior authorizations per week, consuming about 12 hours of physician and staff time. Over a quarter (27%) of these requests are often or always denied, contributing to increased burnout, with 95% of physicians indicating that prior authorization significantly increases their burnout.
• Wasted Health Resources: An overwhelming 87% of physicians stated that prior authorization requirements lead to higher overall healthcare utilization. This includes diversion of resources to ineffective initial treatments, additional office visits, urgent or emergency care, and hospitalizations, indicating significant waste rather than cost savings.

These findings highlight the urgent need for comprehensive reforms in the prior authorization process. The AMA strongly advocates for state-level reforms and supports federal legislation to streamline prior authorization procedures within Medicare Advantage, aiming to prioritize patient access to care, reduce administrative burdens, and preserve resources for high-quality care.

In-Depth Survey Results

The latest "AMA Prior Authorization Physician Survey" underscores the persistent challenges physicians face with prior authorizations, a strategy payers use to ensure necessary treatments. However, most physicians agree that this tactic does not benefit them or their patients.

The survey included 1,000 practicing physicians (400 primary care and 600 specialists), revealing that 94% experience care delays due to prior authorizations, and 78% say that prior authorizations can sometimes lead to treatment abandonment.

For some patients, these outcomes have severe consequences. Almost a quarter (24%) of respondents reported serious adverse events, including hospitalization (19%), life-threatening events (13%), and disability, permanent damage, or death (7%).

Administrative burdens are also a significant concern. Physicians complete an average of 43 prior authorizations per week, with staff dedicating about 12 hours to this task. Some staff members work exclusively on prior authorizations. Moreover, 73% of physicians reported an increase in denials over the past five years, while only 3% saw a decrease. Despite the rise in denials, less than one in five physicians always appeal adverse decisions due to pessimism about success, the urgency of patient care, and insufficient resources.

Even when appeals are made, the process is flawed. Only about 15% of physicians in peer-to-peer reviews believed the health plan's peer had appropriate qualifications, although the frequency of such reviews has increased over the last five years.

Prior authorizations also lead to greater overall healthcare utilization, as reported by 87% of physicians. Ineffective initial treatments (69%) and additional office visits (68%) are primary contributors, with emergency department visits (42%) and hospitalizations (29%) also noted.

NantLink™ - A Streamlined Solution

In response to these challenges, NantHealth introduced NantLink, an innovative electronic health record (EHR) interoperability and point-of-care solution designed to automate provider workflows, reduce administrative burdens, and enhance the healthcare experience.

NantLink integrates seamlessly with Electronic Medical Record (EMR) systems, providing healthcare providers with direct access to insurance information inside of their EMR. This enables them to perform eligibility and benefits (E&B), claims and authorization interactions from the system where they conduct most of their work. This technology aims to enhance workflow efficiency, with the objective of allowing providers to make informed decisions with a more holistic understanding of their patients' medical history and potential risks. NantLink's goal is to simplify collaboration with health plans, making it easier for providers to work directly with them.

The AMA survey highlights the detrimental effects of prior authorization on patient care, physician well-being, and healthcare resources. As the medical community and legislators push for necessary reforms, technologies like NantLink offer a promising solution. Dr. Haris Naseem, CEO of NantHealth, emphasizes, "We aim to empower providers to navigate the complexities of the healthcare system more effectively. NantLink is designed to give providers the tools they need to streamline their workflows and take control of their interactions with insurance companies and pharmaceuticals." With solutions like NantLink, the future of healthcare looks brighter, focusing on connectivity, collaboration, and comprehensive patient care.

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