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March – April 2020
A message from Dr. Marc Keshishian, vice president of Health and Clinical Affairs
Prior authorization process presents an opportunity for collaboration
 When it comes to prior authorization, there’s one thing physicians, hospitals and health plans all agree on — it’s an imperfect process.
An American Medical Association survey found significant dissatisfaction among doctors regarding prior authorization. We’re aware of your concerns and are working hard to partner with our participating health care providers to continue to make improvements in the process.
Let’s first review a few of the reasons we have prior authorization programs in the first place.
- Prior authorization helps ensure that our members have access to appropriate, safe and cost-effective treatment options.
- Prior authorization helps ensure members get the best treatment possible in a health care environment that shows a wide variation in the types of care — and the cost of care — for the same condition. (For more information, see column from Dr. S. George Kipa on variation in clinical care, also in this issue.)
- Prior authorization protects our members by helping eliminate medical errors, while also protecting our members’ pocketbooks.
The cost of care
A recent study found that waste accounts for roughly one-quarter of all U.S. health care spending. According to a Journal of the American Medical Association review of 54 peer-reviewed studies and other information, the cost of waste in the U.S. health care system ranges from $760 billion to $935 billion annually. The study concluded that one-quarter of that could be cut using interventions that can help reduce waste. Prior authorization is one such intervention.
Soaring drug costs are a big contributor to the cost of care. Pharmacy costs represent the largest expense for many health plans. As our members continue to struggle with health care costs, we have a responsibility to double-check on whether exorbitantly priced prescriptions for certain treatments are appropriate. Some drugs can cost tens of thousands of dollars a year, while an alternative course of treatment can cost hundreds of dollars at most. Through prior authorization, we can help identify more cost-effective drug therapies.
Success stories
Prior authorization not only helps to keep the lid on treatment costs, but it contributes to patient safety. Here are two examples that stand out in my mind:
- A Blue Cross prior authorization pharmacist caught a dosing error that could have been fatal for an infant. The baby needed a specialty drug, Acthar® gel, to treat seizures. While the case met prior authorization criteria, the doctor had mistakenly written the prescription for 400 units a day instead of 48. The prescription was corrected, and the baby received the right amount of medication. The extra medication also would have cost an additional $537,000.
- One of our pharmacists noticed that a member with leukemia had prior authorization requests on the same day from two oncologists for two medications. Taking both together would increase side effects, including nausea, vomiting and fatigue, and increase the chance of infection. The medical office staffs at the two practices agreed that the member couldn’t take both medications. The change also saved the cost of the second drug at $13,000 per fill.
While few can argue that prior authorization plays an important role in protecting patients from questionable medications, tests and procedures, there’s no denying that we need to explore ways to speed the process and work more collaboratively with doctors. With that thought in mind, we commit to the following:
- Responding to all prior authorization requests as quickly as possible and in accordance with NCQA guidelines.
- Explore innovative technologies that can streamline the prior approval process, helping to eliminate the need for phone calls and faxes.
- Exempting providers from prior authorization if they consistently order or prescribe treatment and drugs in accordance with evidence-based guidelines or have high prior authorization approval rates.
I recently testified before the state Senate Health Policy and Human Services Committee in Lansing in opposition to legislation that would change the prior authorization and step therapy process. As part of my testimony, I talked about the ways in which prior authorization helps to protect our members’ health and finances. While the legislation, as currently drafted, is well intentioned, we believe it will dramatically increase health care costs for consumers and could negatively affect patient safety.
Let’s keep the conversation going. I welcome your thoughts at MKeshishian@bcbsm.com.
Marc Keshishian, M.D., is vice president of Health and Clinical Affairs for Blue Cross Blue Shield of Michigan, and senior vice president and chief medical officer for Blue Care Network. |
