Photo: Dr. David J. Sand
It’s no secret that burnout is a struggle across the healthcare industry, and the complex, time-consuming prior authorization process is one contributor. In fact, the U.S. Surgeon General addressed this in an advisory this summer aimed at reducing clinician burnout, recommending efficiencies in prior authorization tasks.
Technology can enable electronic prior authorization, a tool in utilization management designed to automate processes and provide faster responses and approvals. This kind of technology may be growing as a necessity, with 84% of physicians reporting increased demand for services and drugs requiring prior authorizations.
Dr. David Sand is chief medical officer of population health company ZeOmega. We interviewed him to talk about technology’s role in reducing the administrative burden for both payers and providers. Here he shares prior authorization challenges he has observed in his experience, and explains how electronic prior authorization can help alleviate these issues.
Q. What are prior authorization challenges for healthcare provider organizations you have observed over the years?
A. The first question a provider typically asks when considering a test or service for her patient is, “Does this require prior authorization?” Providers are justifiably concerned since failure to obtain a required prior auth typically results in denial of payment.
Although similar, each payer has a different list of procedures, services and DME that require prior authorization and knowing if the list the office has is the most current is a challenge. The next issue is keeping track of the various processes, payer portals, fax numbers, passwords and all the other non-clinical details required to submit a request.
No matter the size of the patient panel in a practice, or how many times a patient’s insurance coverage changes, the practice must maintain an accurate and current inventory of each payer’s requirements and details.
Statistics are bandied about regarding the amount of office resources that must be dedicated to the prior authorization process. Typically, a practice that is more procedure-oriented, such as surgery or GI, will have a full-time staff member assigned to the process. Understandably, this is a significant burden to the business of running a practice.
The need to substantiate the medical necessity of a prior authorization request is challenging on two fronts. First, having gone through medical school and residency training, most providers feel they have the appropriate clinical knowledge and expertise to know what’s best for the patient sitting in front of them.
Second, even though the clinical information is in the EHR, it often needs to be extracted and sent with the request. On many occasions, the information sent is insufficient, and the time and resource intensive back and forth between the office and the payer ensues as additional requests and additional documents are exchanged until the prior authorization is issued.
Q. How does the complex prior authorization process contribute to burnout in healthcare?
A. Providers train and dedicate their lives to healthcare to help their patients, not to tend to the administrative and business tasks imposed on them. While younger providers may enter practice with a better idea of the non-clinical tasks with which they must deal, they still may underestimate the burden.
Providers who started their practices prior to the emergence of managed care, clinical pathways, utilization management and optimal recovery guidelines, and the “imposition” of best practice and evidence-based requirements, understandably feel their hard-fought efforts to acquire clinical expertise are being second-guessed by people who have never actually cared for a patient, never taken a phone call in the middle of the night or interrupted family time to run to the ER.
In addition to this sense of devaluation, providers have been increasingly recognizing the difference between the profession and the business of medicine. The two are very different and attention to both is required.
As downward pressure on reimbursement has increased, the additional financial overhead of running the business has increased. Healthcare professionals are smart enough to do the “mental math” – comparing their compensation with the efforts required, and looking at their friends and former classmates who chose different professions.
For years I’ve said that medicine makes you a boring person. Patients want this in their providers – whether they realize it or not. They want a physician who spends her time studying and is one hundred percent dedicated to the practice of medicine rather than playing softball, traveling and going to weekend barbecues with the neighbors.
Most physicians will tell you they abandoned their hobbies some time in medical school with the intention of resuming them once they were in practice – only they never did.
The singular pursuit of medical excellence was gratification enough in years past. The respect that in the past was given to doctors and nurses, the camaraderie and shared experiences of those in the trenches of healthcare, and yes, the compensation and lifestyle, was historically worth the trade-off. No longer.
Q. How does technology enable electronic prior authorization, and what does technology do to the process?
A. The terms I hear most often as I speak with healthcare executives are: automation, efficiencies, optimization. Prior authorization is a highly labor- and resource-intensive process. It is highly regulated in the government-sponsored health plans (for example, Medicare Advantage, Managed Medicaid) and these regulations are passed through to the healthcare providers.
Generally, the providers do not appreciate any value from these regulations but rather, complain that the payers are not holding up their required end of the bargain.
To the extent that automation improves any of the functions composing prior authorization, the effects are experienced by both provider and payer. The efficiencies provided by technological tools should, and do, improve aspects of the prior authorization process such as the time it takes from the submission of the request to the decision and communication of that determination to the physician and patient as well as the level of effort required to support that turnaround time.
Electronic prior authorization brings together previously disconnected technological tools while creating transactional efficiencies at the same time.
The hierarchy of review and the rules and guidelines included; the submission and communication channels, such as portals; the abstraction of medical records from EHRs which contain the documentation that substantiates medical necessity; all require human interaction in the current state and most, if not all, of this intervention can be automated through the electronic prior authorization technology.
Q. How does electronic prior authorization help reduce burnout?
A. The many time-consuming and financially burdensome processes involved in the submission of a prior authorization request, intake of that request, back and forth process of gathering of supporting documentation, manual review of the regulations and guidelines, issuance and communication of the determination, peer-to-peer consultation, appeal and submission of additional information, all contribute to burnout.
These are activities that are physically, financially and emotionally draining for providers of healthcare and are universally viewed as adding no value to healthcare. Electronic prior authorization automates virtually every single step in the process and creates efficiencies that eliminate the financial burden and much of the physical workload.
In the process, the frustrations inherent in the process are relieved and greater satisfaction is achieved with the provision of nearly immediate answers – often while the patient is still sitting with his doctor. Essentially, electronic prior authorization provides a better product with less effort and cost.
The resultant improvements in provider, patient and even payer satisfaction obtained by eliminating the pain points of traditional prior authorization begin to re-balance the forces described above and restore the joy and reward for which most healthcare providers were looking when they initially pursued a career in medicine.
Twitter: @SiwickiHealthIT
Email the writer: [email protected]
Healthcare IT News is a HIMSS Media publication.
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