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AMA Says Prior Authorizations Increasing, Interfering With Care Continuity

(Healthcare Dive) Mar 13, 2019 - The number of prior authorization requirements has increased in the past five years and 85% of physicians say the practice interferes with continuity of care, according to a new survey from the American Medical Association.

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William McGivney, PhD (Posted: March 14, 2019)

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Payer Prior Authorization: Intrusion, Disruption and Patient Harm
Is it any surprise that the frequency of payer prior authorizations continues to rise? The arrogance and greed of the payer/MCO industry dominates good sense and dismisses or, more to the point, disses patient well-being. Oftentimes, prior authorization programs are developed and marketed alone or in combination with other intrusive activities to the employer customers. The sale of such programs generates revenue that hits the bottom line of these payers/MCOs. Did you ever wonder why the Claims Cost totals are generally about 85-88% of the reported Medical Costs of a payer. As the oft-quoted Yogi Berra would say: “You could look it up”; although annual Claims costs are not always easily found.
A significant percentage of the Medical Costs minus Claims paid costs proceed to hit the revenue and profit bottom lines of payers/MCOs. In the drug/biologic world of Oncology, about 1% of prescriptions are ultimately denied. The disruption, delay and harm caused by intrusive prior authorization seems of little consequence to payors/MCOs as they forage and, more accurately, ravage the managed care landscape. I could go on and on but my soon-to-be-released book, On the Road to KICK-ASS HealthCare™ will tell the behind-the-scenes story.
One vignette sums up the absurdity of what we tolerate. An endowed professor at a prestigious Medical Center and longtime NCCN Panel Chair tells the story of what we will generously call a “Peer to Peer” discussion on a prior auth disagreement. The internationally respected medical oncologist found out that she/he was speaking with a cardiology nurse from the payer who proceeded to lecture her/him on what the relevant NCCN Guideline recommended. After exhibiting patience, reserve, and restraint, the good doctor informed the payer cardiology nurse that she/he, indeed, was the chairperson of the relevant panel and had been for many years. She/he then educated the cardiology nurse on what the particular NCCN Guideline really said.
This story might be amusing, if not for the fact that behind the enormous waste of time and money was a patient who thought that he/she had traveled the 300 miles to have this world’s leading oncologist determine what was best for her/him; not some script-bound cardiology nurse in some cubicle otherwise removed from the cancer care delivery system.

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