A central tenet of healthcare quality is patient-centered care. Patient-centered care requires caring for patients and their families in ways that are meaningful and valuable to the individual patient. The Institute of Medicine defined patient-centered care as providing care that is respectful of, and responsive to, individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.1 A patient-centered approach can empower patients to play an active role in their care and assume a pivotal role in developing an individualized, evidence-based treatment plan to meet their healthcare needs. Moreover, patients' satisfaction with care is increased and care quality and outcomes are improved when care is patient centered. The merits of adopting patient-centered care are clear; however, obstacles limit providers' ability to apply this concept in practice. Recent attention has focused on utilization management programs, such as prior authorization, as a significant barrier to patient-centered, evidence-based care that all too often delays the initiation or continuation of necessary medications, durable medical equipment, and other treatment services and negatively affects patient satisfaction and health outcomes.2
Prior authorization is any process by which healthcare providers must obtain advance approval from a health plan before a specific service is delivered to the patient to qualify for payment coverage. Health plans use utilization management programs requiring prior authorization as a measure to control costs, ensure provider compliance with evidence-based clinical guidelines, and promote patient safety. Prior authorization remains a primarily manual, time-consuming process that often delays patient access to indicated therapy or even alters the course of therapy and places excessive burden on providers, including nurses and pharmacists, healthcare practices, and hospitals; disrupts workflow; and diverts valuable resources away from direct patient care.2 Although estimates vary by type and size of healthcare practice, 1 survey found that, on average, in US practices, physicians spent 3 hours per week interacting with payers, nurses spent 19.1 hours, clerical staff spent 35.9 hours, and lawyers/accountants spent 7.2 hours.3 This translates into substantial increase in uncompensated overhead healthcare costs. Furthermore, a critical consequence is nonpayment if prior authorization is not obtained in advance of providing the therapy or service.
The Center for Medicare and Medicaid Services has broadened prior authorization requirements to an increasing percentage of drugs covered under the Part D Prescription Drug Plan and other service types “to ensure beneficiary access and reduce improper payments.”4 Concurrently, recent innovations in cardiovascular care include costly new therapies that are necessitating an increase in prior authorization as the Center for Medicare and Medicaid Services and other health plans strive to control costs. Frequently used cardiovascular therapies requiring often challenging prior authorization include drugs such as platelet aggregation inhibitors, ticagrelor, and prasugrel; novel oral anticoagulant medications, apixaban, dabigatran, and rivaroxaban; PCSK9 inhibitors, evolocumab and alirocumab; the angiotensin-receptor-neprilysin inhibitor, sacubitril/valsartan; and equipment such as Lifevest, a wearable defibrillator. Prior authorization is complicated by requirements for rigorous documentation of response to stepped therapy, including failure to tolerate generic or top tier medications. Navigating this process is complex, time-consuming, and requires constant monitoring of changing health plan prior authorization requirements, formularies, and payment models which may require high patient co-pay even with approved prior authorization.
In late January 2017, the American Medical Association (AMA) convened a coalition including 16 other organizations and patient representatives to create a set of best practices related to prior authorization and other utilization management requirements with the aim of reducing the negative impact on patients, providers, and the healthcare system.2 The AMA has called for reform to increase transparency, streamline requirements, lengthy assessments, and inconsistent rules in current prior authorization programs. To ensure that patients have timely access to treatment and reduce administrative costs to the healthcare system, 21 key utilization management and prior authorization principles for both medical and pharmacy benefits were recommended. The 21 principles were divided into the 5 broad categories described below.2,5
1. Clinical validity. This includes concepts such as utilization management criteria reflecting clinically appropriate care guidelines and not focusing solely on cost containment. Also emphasized is the need for flexibility to address individual patients' clinical situation and needs. Specifically called for are “programs to allow for flexibility, including the timely overriding of step therapy requirements and appeal of prior authorization denials” (Principle 2).
2. Continuity of care. In this category, the 4 principles seek to avoid disruption in patient care due to prior authorization requirements. For example, a minimum 60-day grace period for any step therapy or prior authorization protocols for patients who are already stabilized on a particular treatment upon enrollment in the plan is recommended (Principle 4).
3. Transparency and fairness. The principles in this category address the need for detailed explanations for denials and full public disclosure of all coverage restrictions in a searchable, electronic format. Public disclosure of prior authorization and denial rates and display of accurate, patient-specific, and up-to-date formularies that include prior authorization and step therapy requirements in electronic health record systems for purposes that include e-prescribing are recommended.
4. Timely access and administrative efficiency. These principles establish maximum response times for utilization management decisions and seek health plans' acceptance of electronic prior authorizations. For example, “Eligibility and all other medical policy coverage determinations should be performed as part of the prior authorization process. Patients and physicians should be able to rely on an authorization as a commitment to coverage and payment of the corresponding claim” (Principle 13).
5. Alternatives and exemptions. Principles in this category call for a transition from broad application of prior authorization programs to reduce unjustified administrative burdens on those providers with a clear history of appropriate resource utilization and high prior authorization approval rates. For example, health plans should restrict utilization management programs to “outlier” providers whose prescribing or ordering patterns differ significantly from their peers after adjusting for patient mix and other relevant factors (Principle 19). Another recommendation is “A provider that contracts with a health plan to participate in a financial risk-sharing payment plan should be exempt from prior authorization and step therapy requirements for services covered under the plan’s benefits” (Principle 21).
The AMA offers a prior authorization toolkit and other electronic transaction toolkits for administrative simplification.6 The Prior Authorization Toolkit provides an overview of the current prior authorization landscape, including the status of electronic prior authorization adoption; the toolkit also looks ahead to the future of prior authorization and the industry efforts and changes that will create a more efficient process. The Prior Authorization Tip Guide is designed to help practices minimize the burdens caused by prior authorization and increase the efficiency of authorization.
Current utilization management and prior authorization practices create substantial burden to cardiovascular care providers, including nurses and advanced practice nurses. They limit our capacity to provide patient-centered care and often negatively affect patient satisfaction and outcomes. As cardiovascular nurses, we must join this coalition to drive the necessary reform. The Preventive Cardiovascular Nurses Association supports advocacy on multiple fronts, including partnerships with like-minded organizations, interactions with healthcare plans, state legislation and testimony to federal advisory councils, on behalf of patients, providers, and practices to reduce the excessive burdens of prior authorization and prevent delays in providing high-quality, evidence-based care.
1. Institute of Medicine (US). Crossing the Quality Chasm: A New Health System for the 21st Century
. Washington, DC: National Academy Press; 2001.
3. Casalino LP, Nicholson S, Gans DN, et al. What does it cost physician practices to interact with health insurance plans? Health Aff (Millwood)
. 2009;28(4):w533–w543. doi:10.1377/hlthaff.28.4.w533. PubMed PMID: 19443477.