High-Tech Solutions for Prior Authorization Problems

Nate Gosse, PhD, senior director of oncology solutions mckesson specialty health

Nate Gosse, PhD

Addressing the Challenges of Prior Authorization

Several provider challenges and opportunities were highlighted during the 2017 State Oncology Society Forum, hosted by the National Comprehensive Cancer Network (NCCN) at its annual conference, held in March in Orlando. Presenters and attendees discussed how the application of technology can drive significant near- and long-term benefits by easing prior authorizations (PAs), increasing information exchange, and balancing the roles between technology and human interaction in patient care.PA requirements continue to increase as higher cost treatments, including oral and injectable therapies, are used in the treatment of cancer. Although payers initially developed the process to verify that a treatment is appropriate for a specific patient’s condition before the start of therapy, recent trends have led many providers to conclude that PAs are primarily a subterfuge intended to reduce costs and risk for payers; they have little regard for provider challenges or the burdens they place on patients.

Many oncology practices indicate that the PA workflow and process continue to be frustrating, time consuming, and expensive. Billing staff commonly initiate the process of gathering information and communicating with payers or their intermediaries to confirm that therapies or imaging tests are evidence based. However, the increasingly finegrained inquiries of payers often require the involvement of expert clinical staff and physicians. The labor time and disruptions in workflow can increase costs and delay patient care. Commentary from the podium and audience at recent oncology meetings has suggested these delays can stretch to 2 weeks or longer.

The slowdowns are visibly frustrating for patients and their families who already feel anxious about their diagnoses and impending treatments and are not commonly aware of the behind-the-scenes hurdles their care teams face. These feelings compound with each additional day, as patients wait for scheduling and more information and look to their providers for guidance and affirmation that they’re clear to begin or continue the battle against their disease.

PA difficulties are only growing worse as payers view this process as an acceptable means of data collection and verification; however, this is where technology can improve the situation for patients and their providers. A best practice to help streamline the PA process involves use of decision-support technology that integrates with an electronic health record (EHR) system to give physicians direct visibility of evidence-based treatment options at the point of care. With further clarity on which treatments are recognized by clinical guidelines and pathways, a physician can make recommendations that are likely to meet thresholds for compliance for PA and payment. Access to this information at the point-of-care leads to a quicker turnaround time for PAs and means patient delays and anxiety are minimized.

These tools also can ensure all necessary clinical data have been considered and captured, streamlining the workflow of the business office and clinical staff by easing the burden of paperwork, number of clicks, and other time spent on PAs. Integrating a decision-support system with Web-based PA portals can help to initiate cases and eliminate manual re-entry of patient details, further reducing delays and staff burden.

Sharing Information Between Systems

When choosing technology, a practice should find a solution that offers point-of-care access to the library of NCCN Guidelines—the most widely recognized clinical treatment recommendations in oncology. From their technology, providers should also expect narrower clinical pathways, visibility into treatment cost, and the ability to highlight payer-specific preferences (or coverage) for patients. The ability to directly transmit required information for PA submissions and to provide real-time reporting and physician feedback will ensure that the challenges of PA can be minimized. This will enable physicians to focus on practicing medicine, not negotiating with payers.In the consumer world, we quickly become irritated if we are repeatedly asked to provide the same information to complete a transaction. Yet in healthcare, we are only now moving to an era in which the same information or data can be repurposed to complete multiple tasks.

From the EHR to billing and practice management, inventory management, decision support tools, and patient portals, providers rely on multiple tools to collect and manage data related to patient care. When these systems are not working together or sharing data, it becomes necessary to manually enter that data into multiple systems. Not only is this tremendously inefficient, but the risk of error increases. For many providers, their health information technology (HIT) remains in an awkward adolescence. Oncology is further challenged by the rapidly increasing depth of clinical content, terminology, and values that are required to deliver appropriate patient care.

The current push by payers toward value-based payment makes interoperability more important than ever. Practices face new requirements to merge clinical and financial data, and successful performance requires fast and accurate understanding of costs, quality, use, and other outcomes.

Balancing Technology with Human Approach

Significant strides have been made in the realm of interoperability. Static standards have given way to extensible toolkits, like Fast Healthcare Interoperability Resources. Savvy HIT vendors now offer not just closed-off tools, but open platforms and suites of solutions that share information and work together to lower costs, increase access, and improve the quality of care. A practice looking to implement any type of HIT system should partner with a vendor that will consider the interoperability of all of applicable systems.Looking to the future, it’s beginning to appear that one day, a computer will be able to simulate how the human brain works. In just the last 6 months, learning systems have outperformed humans in everything from driving cars to playing high-stakes poker. The promises of Big Data and cognitive computing in healthcare have yet to become a reality, but as these advancements make their way from pilot programs to everyday practices, providers are asking when it is best to still have human interactions and decision making.

Large amounts of information can be overwhelming at best and counterproductive or dangerous at worst—everyone in the industry is familiar with this challenge. But technology is excellent at applying logic and capturing, managing, and storing data. Our reliance on modern search engines and smartphones is an example of the value of being able to organize mountains of information to gain insight from it.

In a similar sense, Big Data, clinical algorithms, and cognitive computing—properly coupled with an understanding of workflow and operations—have the potential to enhance care. Early pilots of cognitive computing systems and the wide customer footprint and quantitative benefit of clinical pathways highlight the opportunities here.

Even so, physicians and their supporting care teams have access to far more information than is captured in systems, and there are many aspects of care that technology cannot replace. For example, every patient has different values and priorities when it comes to care. There are cultural differences and emotional reactions to consider when discussing diagnoses, and the best treatment option or end-of-life care decision is not always identifiable from structured data and algorithms. In these situations, nothing can replace the human aspect of care and the need for providers to stay closely connected with their patients.

Leading HIT systems are fine tuned to clinical workflows and offer the flexibility to incorporate future advancements in cognitive computing. However, all will face the challenge to balance the use of these sophisticated capabilities to complement human caregivers, not distract them or attempt to replace them.

HIT presents boundless opportunity to address many of the challenges practices face in the rapidly evolving marketplace. But significant risks persist, and having a well thought out strategy and capable partners are essential for optimizing practice operations and payment, as well as for allowing a focus on quality patient care. Comprehensive workflow and billing support, managed clinical content, and user- and IT staff— friendly cloud-based systems are no longer enough. Winning providers need to organically extend systems with decision support and tools that minimize the burden of PA, adopt interoperability to enable modular applications that support value-based care, and have the foresight to enable integration to benefit from advancements in data processing and cognitive computing.