Industry Insider News

Prior Authorization Leads to Serious Adverse Events, AMA Survey Claims 
More than 25% of physicians report that serious or life-threatening events for patients have resulted due to the prior authorization process required by health insurers for certain drugs, tests, and treatments. According to new survey results recently released by the American Medical Association (AMA), the prior authorization process as a whole continues to have a distressing impact on patients and physician practices. Despite widespread calls for meaningful reform during the last two years, the survey illustrates that prior authorization programs and existing processes remain costly, inefficient, opaque, and, in some cases, hazardous, according to the survey of 1,000 practicing physicians.

“The AMA survey continues to illustrate that poorly designed, opaque prior authorization programs can pose an unreasonable and costly administrative obstacle to patient-centered care,” said Jack Resneck, Jr., MD, AMA chair. “The time is now for insurance companies to work with physicians, not against us, to improve and streamline the prior authorization process so that patients are ensured timely access to the evidence-based, quality healthcare they need.”

Other physician concerns highlighted in the AMA survey include:

• More than nine in 10 physicians (91%) say prior authorization programs have a negative impact on patient clinical outcomes.

• Nearly two-thirds of physicians (65%) report waiting at least one business day for prior authorization decisions from insurers – and 26% say they wait three business days or longer.

• More than nine in 10 physicians say the prior authorization process delays patient access to necessary care, and 75 percent of physicians report that prior authorization can at least sometimes lead to patients abandoning a recommended course of treatment.

• A significant majority of physicians (86%) say the burdens associated with prior authorization are “high” or “extremely high,” and a clear majority (88%) believe burdens associated with prior authorization have increased during the past five years.

• Each week, a medical practice completes an average of 31 prior authorization requirements per physician, which take the equivalent of nearly two business days (14.9 hours) of physician and staff time to complete.

• To keep up with the administrative burden, more than one-third of physicians (36%) employ staff members who work exclusively on tasks associated with prior authorization.

“The AMA is committed to attacking the dysfunction in healthcare by removing the obstacles and burdens that interfere with patient care,” Resneck said. “To make the patient-physician relationship more valued than paperwork, the AMA has taken a leading role by creating collaborative solutions to right-size and streamline prior authorization, and help patients access safe, timely, and affordable care while reducing administrative burdens that pull physicians away from patient care.”

In January 2017, the AMA and 16 other associations urged industry-wide improvements in prior authorization programs to align with a newly created set of 21 principles intended to ensure that patients receive timely, medically necessary care and medications and to reduce administrative burden. More than 100 other healthcare organizations have supported those principles, according to the AMA. In January 2018, the AMA joined the American Hospital Association, America’s Health Insurance Plans, American Pharmacists Association, Blue Cross Blue Shield Association, and Medical Group Management Association in a consensus statement outlining a shared commitment to industry-wide improvements to prior authorization processes and patient-centered care. The AMA welcomes the opportunity to work collaboratively with health plans and others to create a partnership that lays the foundation for a more transparent, efficient, fair, and appropriately targeted prior authorization process, AMA officials said. Visit www.ama-assn.org to learn more about the organization’s ongoing collaborative efforts. n

Net Health’s Wound Expert Earns National Certification
Officials at Net Health, Pittsburgh, PA, a leader in software solutions for specialized outpatient care, recently announced that the company’s electronic health record (EHR) WoundExpert^® version 7.0 has achieved Office of the National Coordinator for Health Information Technology (ONC-Health IT) 2015 Edition Health IT Module Certification via Drummond Group LLC, an authorized certification body (ACB) that has been empowered to test software for compliance with the requirements of the federal government’s program. The stamp of approval designates that the software offers the functionality that enables eligible clinicians and hospitals to meet the requirements of various regulatory programs that require use of certified EHR technology.

“It's imperative for our clients’ success that our software solutions adhere to industry standards for compliance,” said Christopher Hayes, chief technology officer at Net Health. “This 2015 Edition certification represents a dependable and reputable public benchmark that WoundExpert continues to serve clients with the ONC’s latest privacy and security requirements, and furthers interoperability with high-quality data exchange.”

To earn the certification, WoundExpert was tested to be in accordance with applicable standards and certification criteria put forth by the Department of Health & Human Services (HHS), officials said. WoundExpert provides clients who are designated as “eligible clinicians” by the Centers for Medicare & Medicaid Services the tools needed to participate in the Merit-Based Incentive Payment System for the 2019 performance period. Net Health’s cornerstone of success is to provide solutions that allow clients to confidently focus on treating their patients. In support of that goal, this 2015 Edition certification highlights improved interoperability, driving better coordination of care for patients throughout the continuum, and facilitates increased patient engagement through access to their health information via a revamped patient portal.

“The level of focus and perfection required for any solution to achieve 2015 Edition certification was raised to a level unlike the prior two certifications — and our team delivered,” Hayes said. “Current compliance trends, like giving patients quick access to their data to help paint a full picture of their healthcare, are exciting enhancements to deliver.” This Health IT module is 2015 Edition compliant and has been certified by an ONC-ACB in accordance with the applicable certification criteria adopted by the Secretary of the HHS. This certification does not represent an endorsement by the HHS. WoundExpert version 7.0 was certified on Dec. 31, 2018, by Drummond Group. For more information, visit www.nethealth.com.