HHS’ ONC division wants streamlined prior authorization, better price transparency
Thursday, June 13, 2019
The United States Department of Health and Human Services (HHS) is having a busy time. In addition to its effort to provide clarity for its interoperability rule, the department announced that it’s looking for ways electronic prior authorization can be improved.
Don Rucker, head of the Office of the National Coordinator for Health IT, said at Academy Health's annual research conference in Washington, D.C., in early June that the current state of prior authorization, including the requirement that providers obtain approval from a patient's insurance before prescribing medication or therapy, is a "non-computerized kabuki of payment" that "needs to get rethought."
Per Rucker, ONC's current goal in this regard is to reintegrate financial, clinical and quality data within health IT transactions. "Prior auth may be the battlefield to do that," he said at the event.
Prior authorization is a headache for provider organizations. Administrative burden is a primary claim, and can stop patients from receiving care.
Prior authorization applies to less than 15% of covered healthcare services, according to payer group America's Health Insurance Plans (AHIP).
AHIP says any additional overhead on providers is relatively uncommon and the scrutiny of prior authorization pays off by weeding out unneeded care. Health insurers report almost 30% of these requests are for care not supported by clinical evidence.
Payers — the financial gatekeepers — say that the practice keeps costs down by denying unnecessary care.
According to the American Medical Association, 28% of providers reported PA affected care delivery and led to a serious adverse event.
There's evidence to back that claim up. A 2017 Government Accountability Office report found prior authorization saved Medicare as much as $1.9 billion from its beginning in seven states in 2012 through March 2017.
Payer groups AHIP and the Blue Cross Blue Shield Association came together with the AMA, American Hospital Association, American Pharmacists Association and Medical Group Management Association to release a “Consensus Statement on Improving the Prior Authorization Process.”
One popular solution supported by the coalition is electronic prior authorization (ePA).
Electronic prior authorization could save the industry almost $420 million per year, with providers recouping roughly $280 million alone, according to healthcare business processes nonprofit CAQH.
"The question is, why is it not used more?" Rucker asked.
ONC also is attempting to stop information blocking between disparate health IT networks. The agency, along with CMS, released two interoperability rules implementing key provisions of the 21st Century Cures Act in an attempt to foster increased data sharing within healthcare.
The comment period closed June 3 at midnight. More than 2,800 comments were received related to two HHS rules meant to promote interoperability and discourage information blocking. Most in healthcare are fine with the generalities of the rule, but some are at odds with it.
The quick implementation timeline; proposal to publicize prices; requirement that providers share with a patient's team when they're admitted, transferred or discharged; matching patients to their correct medical record; and perennial concerns with data privacy and security took up the bulk of healthcare groups' concerns.
More clarity is needed around the exceptions to info blocking, many say, adding that the burden of reporting lies with hospitals.
CMS' rule proposes requiring Medicaid, the Children’s Health Insurance Program, Medicare Advantage plans, and health plans in the Affordable Care Act exchanges to provide their combined 125 million patients with free electronic access to their personal health information, including claims, by 2020.
ONC wants to require the industry to adopt standardized application programming interfaces (APIs), which allow computer systems to talk to each other. It would also require health IT vendors and providers come into compliance with provisions to stop information blocking the day after the rule is finalized.
Health information exchange nonprofit The Sequoia Project, which includes major EHR vendors like Epic, Cerner and Athenahealth, along with some providers, called the rule "overly aggressive."
Stakeholders suggested varying implementation guidelines, including up to 36 months minimum for providers to make sure their health IT programs are up to date with the rules. "Given the magnitude of changes encompassed in these rules, CMS and ONC should be publishing interim final rules rather than final rules to allow additional opportunity for stakeholder comments," the College of Healthcare Information Management Executives (CHIME) said in its comments.
Some argue that the price transparency set about in the rule would reduce competition and disrupt negotiations with plans.
The scores of individual comments and stories were driven in part by advocacy group Patient Rights Advocate, run by Cynthia Fisher, who is also a member of the Health IT Advisory Committee. This group, created under the 21st Century Cures Act to advise ONC, also recommended ONC remove price transparency stipulations from the rule over concerns it could slow down the rule's finalization.
"Patients may be unaware that once they authorize a covered entity to push their health information to a third-party app and such an entity is a HIPAA non-covered entity, the rights afforded under HIPAA no longer apply," AHIMA wrote.
Additionally, patients may not know how an app intends to use their sensitive health information, or the app may not have invested strongly in security. Comments recommended the administration clearly regulate what actors are liable for data breaches and when.
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