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Streamlining and Reimagining Prior Authorization Under Value-Based Contracts: A Call to Action From the Value in Healthcare Initiative's Prior Authorization Learning Collaborative.

Publication ,  Journal Article
Psotka, MA; Singletary, EA; Bleser, WK; Roiland, RA; Hamilton Lopez, M; Saunders, RS; Wang, TY; McClellan, MB; Brown, N ...
Published in: Circulation. Cardiovascular quality and outcomes
July 2020

Utilization management strategies, including prior authorization, are commonly used to facilitate safe and guideline-adherent provision of new, individualized, and potentially costly cardiovascular therapies. However, as currently deployed, these approaches encumber multiple stakeholders. Patients are discouraged by barriers to appropriate access; clinicians are frustrated by the time, money, and resources required for prior authorizations, the frequent rejections, and the perception of being excluded from the decision-making process; and payers are weary of the intensive effort to design and administer increasingly complex prior authorization systems to balance value and appropriate use of these treatments. These issues highlight an opportunity to collectively reimagine utilization management as a transparent and collaborative system. This would benefit the entire healthcare ecosystem, especially in light of the shift to value-based payment. This article describes the efforts and vision of the multistakeholder Prior Authorization Learning Collaborative of the Value in Healthcare Initiative, a partnership between the American Heart Association and the Robert J. Margolis, MD, Center for Health Policy at Duke University. We outline how healthcare organizations can take greater utilization management responsibility under value-based contracting, especially under different state policies and local contexts. Even with reduced payer-mandated prior authorization in these arrangements, payers and healthcare organizations will have a continued shared need for utilization management. We present options for streamlining these programs, such as gold carding and electronic and automated prior authorization processes. Throughout the article, we weave in examples from cardiovascular care when possible. Although reimagining prior authorization requires collective action by all stakeholders, it may significantly reduce administrative burden for clinicians and payers while improving outcomes for patients.

Duke Scholars

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Published In

Circulation. Cardiovascular quality and outcomes

DOI

EISSN

1941-7705

ISSN

1941-7713

Publication Date

July 2020

Volume

13

Issue

7

Start / End Page

e006564

Related Subject Headings

  • Value-Based Purchasing
  • Value-Based Health Insurance
  • Stakeholder Participation
  • Quality Indicators, Health Care
  • Quality Improvement
  • Prior Authorization
  • Policy Making
  • Organizational Innovation
  • Humans
  • Health Care Costs
 

Citation

APA
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Psotka, M. A., Singletary, E. A., Bleser, W. K., Roiland, R. A., Hamilton Lopez, M., Saunders, R. S., … American Heart Association Prior Authorization Learning Collaborative*, . (2020). Streamlining and Reimagining Prior Authorization Under Value-Based Contracts: A Call to Action From the Value in Healthcare Initiative's Prior Authorization Learning Collaborative. Circulation. Cardiovascular Quality and Outcomes, 13(7), e006564. https://doi.org/10.1161/circoutcomes.120.006564
Psotka, Mitchell A., Elizabeth A. Singletary, William K. Bleser, Rachel A. Roiland, Marianne Hamilton Lopez, Robert S. Saunders, Tracy Y. Wang, Mark B. McClellan, Nancy Brown, and Nancy American Heart Association Prior Authorization Learning Collaborative*. “Streamlining and Reimagining Prior Authorization Under Value-Based Contracts: A Call to Action From the Value in Healthcare Initiative's Prior Authorization Learning Collaborative.Circulation. Cardiovascular Quality and Outcomes 13, no. 7 (July 2020): e006564. https://doi.org/10.1161/circoutcomes.120.006564.
Psotka MA, Singletary EA, Bleser WK, Roiland RA, Hamilton Lopez M, Saunders RS, et al. Streamlining and Reimagining Prior Authorization Under Value-Based Contracts: A Call to Action From the Value in Healthcare Initiative's Prior Authorization Learning Collaborative. Circulation Cardiovascular quality and outcomes. 2020 Jul;13(7):e006564.
Psotka, Mitchell A., et al. “Streamlining and Reimagining Prior Authorization Under Value-Based Contracts: A Call to Action From the Value in Healthcare Initiative's Prior Authorization Learning Collaborative.Circulation. Cardiovascular Quality and Outcomes, vol. 13, no. 7, July 2020, p. e006564. Epmc, doi:10.1161/circoutcomes.120.006564.
Psotka MA, Singletary EA, Bleser WK, Roiland RA, Hamilton Lopez M, Saunders RS, Wang TY, McClellan MB, Brown N, American Heart Association Prior Authorization Learning Collaborative*. Streamlining and Reimagining Prior Authorization Under Value-Based Contracts: A Call to Action From the Value in Healthcare Initiative's Prior Authorization Learning Collaborative. Circulation Cardiovascular quality and outcomes. 2020 Jul;13(7):e006564.

Published In

Circulation. Cardiovascular quality and outcomes

DOI

EISSN

1941-7705

ISSN

1941-7713

Publication Date

July 2020

Volume

13

Issue

7

Start / End Page

e006564

Related Subject Headings

  • Value-Based Purchasing
  • Value-Based Health Insurance
  • Stakeholder Participation
  • Quality Indicators, Health Care
  • Quality Improvement
  • Prior Authorization
  • Policy Making
  • Organizational Innovation
  • Humans
  • Health Care Costs