Latest / Becker’s Payer Issues Podcast / Charting the Path for Electronic Prior Authorization

Transcript

Charting the Path for Electronic Prior Authorization · Becker’s Payer Issues Podcast

0:00
Hi, everyone. This is Lucas Voss with Becker's
0:02
Healthcare. Thanks so much for tuning in to
0:04
the Becker's Healthcare podcast series. Fantastic to have
0:07
you. An exciting topic today, strategies for progress
0:11
around e prior authorization in a complex landscape.
0:14
And I'm
0:16
very excited to be joined by Steven Berko,
0:18
senior advisor, value based care inner systems, and
0:21
Robert Tennant, executive director at the work group
0:24
for electronic data interchange or WEDI.
0:28
Steven and Robert, thanks so much for being
0:29
here today. It's great to have you.
0:31
Thanks for having us. Appreciate it. I wanna
0:34
start off with introductions for our audience here.
0:37
Steven, why don't you kick us off? Could
0:39
you just give us a little bit of
0:40
background on yourself and and your work in
0:42
health care? Yeah. Sure. Happy to. I've been
0:44
kicking around health care for almost thirty years.
0:46
I,
0:47
have been in the start off as an
0:49
executive on the provider side and then through
0:52
acquisition, actually switched over to the, health plan
0:55
side.
0:56
And along the way, I just have become
0:58
increasingly convinced
1:00
if,
1:01
we're truly gonna advance the, quadruple aim or
1:04
value based care in health care,
1:06
we have got to figure out how to
1:08
fully harness the power of data.
1:11
So about a year ago, I moved over
1:14
to intersystems thinking,
1:16
what's a better place to try to advance
1:18
that kind of calling
1:20
than to be inside kind of a worldwide
1:22
leader in health care interoperability
1:24
with special expertise
1:26
in, integrating clinical data. So that's how a
1:29
GM
1:30
who's not
1:31
a coder wound up at InterSystems.
1:34
Well, it's great to have you. Thanks for
1:35
being here. Robert, we'll kick it over to
1:37
you.
1:38
Yeah.
1:40
Pleasure to join,
1:41
Steve and on this podcast.
1:43
I've been in health care for almost as
1:45
long.
1:46
I spent almost twenty five years at the
1:48
Medical Group Management Association
1:52
as the director of,
1:54
health information technology
1:56
policy.
1:57
And then I,
1:58
transitioned over to WEDI
2:01
about five years ago
2:03
and then, became executive director earlier this year.
2:07
For those that aren't familiar with WEDI, we
2:10
were named in HIPAA as an adviser
2:13
to HHS,
2:14
and we represent,
2:16
really the the broad
2:17
spectrum of health care. Everybody from the health
2:20
plan side to the provider side,
2:23
associations,
2:24
vendors, clearing houses,
2:26
standards development organizations, and, actually,
2:30
federal and state
2:31
government. Both, CMS and ASTP ONC
2:35
serve on the WEDI board of directors.
2:38
It's so great to have you both on.
2:40
Both great perspectives for this topic, I think.
2:43
And I wanna start off with just sort
2:44
of level setting,
2:46
the situation that we're in and what we're
2:48
talking about today.
2:49
There is a lot of talk about the
2:50
regulatory mandate around e prior authorization, a lot
2:50
of conversation. It's regulatory
2:53
mandate around e prior authorization, a lot of
2:55
conversation. It's widely seen as a step forward
2:57
by most,
2:58
but there's also limits, important limits that come
3:00
with it. I'd love to get both of
3:02
your perspectives on this. What should health system
3:05
leaders understand about the mandate, what the mandate
3:08
does, and really doesn't address? Steven, why don't
3:11
we start with you?
3:13
I I think one of the things that's
3:15
you know, that always brings Rob and I
3:16
together in conversations
3:17
is we both work with
3:20
cross constituency.
3:22
So we both work with health plans. We
3:24
both I'm a vendor, so he works with
3:26
me,
3:26
but we both work with providers. We work
3:29
with HIEs.
3:30
We work with QHIMs.
3:32
We're supporting them.
3:34
Rob's team is representing them, trying to,
3:37
and I and I think, like, the big
3:39
thing that I think when you start to
3:40
think about all those constituencies,
3:42
so outside of the government at this point,
3:45
is balls in your court.
3:47
And the, I think sometimes people construe what's
3:49
in o o five seven with regard to
3:51
EPA
3:52
as, you know, a lockstep
3:54
map for how we're gonna get to electronic
3:57
prior authorization.
3:59
And what the government has really done
4:01
is just given us enough of the blueprint
4:04
to get going, to try to say, let's
4:07
pull health care into the modern data exchange
4:10
via APIs.
4:13
But in terms of how that's gonna build
4:14
out to the plan back end, how that's
4:16
gonna reach out to the providers, there's a
4:18
lot that's been left to the private sector
4:21
to figure out.
4:22
And so if we wanna get compliance to
4:24
actual value,
4:26
I I actually think it's good news. You
4:28
know, sometimes people are like, wait a minute.
4:29
But the government hasn't exactly specified how to
4:32
do this. But on the other hand, when
4:34
you really talk with people, don't you wanna
4:36
be able to fill that in yourself knowing
4:38
that you're the people who are gonna actually
4:40
have to perform against it?
4:42
Robert, I'm sure, you echo some of this
4:44
similar perspective. I'd love to get your thoughts
4:47
as well.
4:48
Yeah. Yeah. I'll I'll I'll tackle the question
4:51
from the policy side.
4:53
It's a it's been a long time coming.
4:55
I think we've seen
4:57
survey results coming out from provider associations
5:00
indicating that
5:02
this issue prior authorization is the leading administrative
5:05
burden,
5:06
that they believe is facing
5:09
Madison today.
5:11
I think this rule that came out in
5:13
early January twenty twenty four
5:16
was the culmination
5:17
of a lot of issues. I think, we
5:20
saw some movement on Capitol Hill there. There
5:23
was a bipartisan,
5:24
bicameral,
5:26
effort to pass legislation, which would essentially do
5:30
what this regulation
5:31
does,
5:33
also include transparency. It's a big part of
5:35
of the final rule is the requirement for
5:38
health plans to let,
5:40
you know, patients and, policymakers
5:43
know what the landscape looks like for prior
5:46
authorization. How many are approved? How many are
5:49
denied? So I think there was some public
5:52
pressure
5:53
put on the industry to tackle this particular
5:57
issue. And we saw, of course, the first
5:59
iteration of the rule came out in December
6:02
2020
6:03
under the first Trump administration.
6:05
The Biden administration
6:07
actually expanded
6:08
that to include Medicare Advantage,
6:11
and so that's where we sit now.
6:13
But I think, as Stephen said, it's really
6:16
a transformation
6:18
of the way
6:19
prior authorization
6:20
data is exchanged, and I think that's the
6:23
exciting part.
6:25
I think, again, it's happened because,
6:28
the current,
6:30
electronic data interchange
6:32
standard known as the x twelve two seventy
6:35
eight transaction
6:36
really didn't get much traction in the industry.
6:40
So
6:41
providers,
6:42
and payers were relying on fax machines, on
6:44
on portals, on phone calls,
6:47
and it's simply not sustainable. So I think
6:50
the rule begins to move the industry forward.
6:54
And speaking of that, Robert, just staying with
6:56
that, just as a follow-up to that, you
6:58
mentioned moving forward and you've also talked about
6:59
the landscape and, obviously, the changing piece of
7:01
this.
7:02
How how are you seeing this change, especially
7:05
when we look at the start of 2027?
7:07
How how are you anticipating the EPA landscape
7:09
to change?
7:11
Yeah. I think,
7:12
what we're seeing is sort of a a
7:15
coalescing
7:16
around the the rule. It's not a rule
7:19
that we're seeing a lot of pushback on.
7:21
I think in particular,
7:23
because commercial plans were not covered under the
7:26
rule, there was some concern that the commercial
7:29
lines of business would not support
7:32
this new FHIR based API approach to to,
7:36
e prior authorization.
7:37
That does not appear to be the case.
7:39
It looks like the the payer industry is
7:42
moving forward in in lockstep.
7:45
Obviously, there's gonna be,
7:47
variations
7:48
on how each health health plan
7:51
interprets the rule and implements it. But I
7:54
think the consensus
7:55
is that this is long overdue, and it's
7:59
a a wonderful
8:00
step forward for the industry. So I would
8:03
say very hopeful
8:04
that, the industry will, see some success early
8:08
in '27.
8:09
Yeah. Lucas, I I think it's very important
8:11
that everybody on the line understand
8:13
why the start of 2027
8:15
is so important. So there's a couple of
8:17
effective dates in the regulation,
8:20
but the big one is 01/01/1927
8:23
when, you know, you have to be compliant
8:25
with the regulation. So it's it's a great
8:27
question.
8:28
And I think what people are starting to
8:30
realize is it's not gonna be like a
8:32
light switch is gonna get flipped. And increasingly,
8:35
there's discussions that if we really want to
8:38
kind of transform,
8:40
we can't we can't forget the principles of
8:42
change management.
8:44
And that the way the rule is written,
8:46
it doesn't mandate that all providers must move
8:49
to EPA.
8:50
In effect, it provides this blueprint.
8:53
It's a better way. It's using modern APIs
8:56
that everybody wants to migrate to. But I
8:58
think that the, industry is beginning to recognize
9:01
that it's really, really important
9:03
that once these solutions go live, they have
9:06
to work
9:07
because providers are still gonna have the option
9:10
for phone and fax.
9:12
So it's very, very important. I mean, we
9:14
spent a lot of time working with our
9:16
clients on
9:17
on mapping and testing because what we know
9:20
from our conversations with provider leaders,
9:23
you know, you're gonna get one or two
9:24
bites of the apple,
9:26
and then people are going to begin to
9:28
kind of decide, hey. Is this better for
9:31
me or worse for me? And if they
9:33
don't have a good experience upfront, it's gonna
9:36
be very, very difficult to overcome that. So
9:38
we really encourage people to think about,
9:41
hey.
9:42
Do what you say well. Don't try to
9:45
do everything upfront if you don't have to.
9:47
Figure out what those providers really want
9:49
to embrace this and be sure that works.
9:53
Which also brings me to my next point,
9:55
right, is you've talked about the the conversations
9:57
that you're having with folks. You both are
9:59
are very actively connecting people
10:02
in the industry to be able to have
10:04
these these conversations. You you bring them together.
10:07
You connect them to to talk about it,
10:09
to to bring exercises together, to be able
10:12
to practice this together, to see what happens.
10:14
I'd love to know in these conversations, in
10:17
these get togethers, in these exercises, right, that
10:20
that you're doing with providers, plants, vendors, etcetera,
10:23
all of these elements,
10:25
what are the barriers that you're talking about?
10:27
You've mentioned some of them in in our
10:28
previous answer here, but what are some of
10:30
the answers that come up most consistently
10:32
as obstacles to that nationwide adoption that we
10:35
talked about? Robert, why don't we start with
10:37
you?
10:38
Well, I'll start by saying,
10:40
first of all, it's the nature of prior
10:43
authorization.
10:44
It is not a binary
10:46
simple transaction.
10:48
We call it a conversation
10:50
rather than a a transaction. So there's a
10:53
lot of moving parts, a lot of back
10:55
and forth, much more so than, let's say,
10:58
a claim. And so the health plans have
11:01
developed,
11:02
over the years,
11:03
medical necessity policies
11:06
that
11:07
are aren't naturally conducive to moving into an
11:10
API environment.
11:12
So right from the start,
11:13
trying to make sure that they're able to,
11:16
in real time,
11:18
give an answer to the provider when they
11:20
ask, does this service require
11:23
a prior authorization?
11:24
Yes or no.
11:26
That itself is a complicated question because there
11:29
are elements of well, it depends. If you
11:32
perform this service in the past, then no.
11:35
There's also the issue of gold karting. So
11:38
all of these data streams have to flow
11:41
together. I think as as payers
11:43
and their vendor partners are looking at this,
11:46
they're trying to solve these these problems.
11:49
But,
11:50
I think Steven alluded to the fact that
11:53
providers are not required. They're not named in
11:56
the law to meet this
11:58
compliance date. They do have a bit of
12:01
a carrot and stick with the
12:03
EHR incentive
12:05
program so they could lose out on some
12:08
incentive
12:09
monies. But how do you convince a provider
12:12
to adopt the technology? It's not gonna be
12:15
cheap,
12:16
especially if not all of their health plans
12:18
are going to be supporting it. So I
12:20
think it's a bit of a chicken and
12:22
egg, but I'm hopeful that once the commercial
12:26
plans step up and begin to offer this
12:29
as an option and the providers realize
12:32
that this presents
12:34
a solution to what they consider to be
12:36
the most burdensome
12:38
administrative issue, I'm confident that that will be
12:41
able to go forward. So can I get
12:43
really weedy about this pun intended?
12:46
You may. Yes.
12:47
Excellent.
12:48
Yeah. We really have been doing root causes.
12:50
So I think what people need to know
12:53
is that
12:54
there have been a number of very limited
12:57
pilots
12:58
that have really proved the concept.
13:01
On a limited basis,
13:03
you know, we have been able to show
13:04
that you can dramatically actually reduce the number
13:08
of prior authorization
13:09
requests that are required. You can dramatically reduce
13:12
the amount of human time needed to process
13:15
things.
13:16
There's been a strong proof of concept that
13:18
there's a win win win here, but those
13:20
have been for very limited,
13:23
you know, datasets and groups and whatnot. And
13:25
what we're seeing
13:27
is the industry is struggling to scale. Right?
13:30
We wanna transform. We wanna do this for
13:32
everyone, and it's very hard to get there
13:34
by making point to point connections. And what
13:36
I mean that is each plan having to
13:39
connect individually with each provider organization and vice
13:42
versa.
13:43
So I started doing these,
13:45
root cause sessions
13:47
with different constituencies to understand what's blocking, what's
13:50
it gonna take to scale, and Weedy actually,
13:53
helped me with that recently. A couple months
13:55
ago in Chicago,
13:56
we got we brought together a 100
13:59
leaders, most in person, a few virtually.
14:02
And, quantitatively,
14:03
there was actually a real answer. There were
14:05
really two things that popped
14:07
in terms of, at least right now, what
14:08
are the primary barriers.
14:10
Number one, it's this this age old thing
14:13
that we still have too many siloed systems
14:16
that speak different different formats
14:19
in EPA. So even though the government has
14:22
established
14:23
that we're gonna have APIs in the center
14:25
of the communication,
14:26
On both sides, we're gonna have to get
14:28
things into a common FHIR format to facilitate
14:31
that exchange. And then the other thing
14:34
is actually
14:35
not technical.
14:37
It's just the aversion to change.
14:40
And what we have to recognize, and it
14:41
goes back to a little bit about if
14:44
we're gonna transform, it's not all about the
14:46
technology.
14:47
Maybe said poorly,
14:49
there are a lot of people out in
14:50
health care who are very, very good at
14:53
making this very inefficient EPA system work.
14:56
So we're gonna have to ask people to
14:58
make a lot of changes in terms of
15:00
how they do their workflows. There's people who
15:02
understand how to get prior authorizations
15:04
approved via phone and fax.
15:07
So, I mean, that's the other thing. I
15:08
think we have to recognize
15:10
that as we're trying to leap forward to
15:13
this new way of doing prior authorization,
15:16
we gotta figure out a way to bring
15:17
along all these people who are very good
15:20
at making what I call a broken system
15:22
work. So with all of these people and
15:24
you mentioned the win win win. Right? And
15:26
you've also talked about all of these different
15:27
elements that are involved in this process.
15:30
Is there a right way forward? Is there
15:31
consensus?
15:32
Or is it completely different depending on who
15:35
you're talking to? Well, I mean, at a
15:37
100,000 feet,
15:39
absolutely. And there's some very good news. There's
15:41
a,
15:42
a multi,
15:44
segment group. It's called the DaVinci Group, and
15:47
they have put out these things called IGs.
15:49
And there's three of them called the burden
15:51
reduction IGs
15:53
that are actually highly recommended in the regulation
15:56
as the right path to leap forward to
15:59
this new way of doing prior authorization.
16:02
And the good news is
16:04
you gotta look pretty far now,
16:07
to find somebody who doesn't think at a
16:09
100,000
16:10
feet, the right way forward is actually to
16:13
achieve electronic prior authorization, EPA,
16:17
by implementing
16:18
these three burden reduction IGs.
16:22
So 100,000 feet, conceptually, yeah, I think most
16:26
people are on board. The challenge, of course,
16:28
is when you come down to 10,000 feet.
16:30
And I think what people have to recognize
16:33
is, yeah, I said win win win, but,
16:35
you know, historically,
16:37
prior authorization has been a huge point of
16:39
tension
16:40
between providers and payers.
16:43
And,
16:44
we are struggling, shall I say, maybe to
16:47
build trust. We all wanna get to the
16:49
future. We, you know, we kinda know what
16:51
that future looks like,
16:53
but, you know, there's, like you know, some
16:55
of the sessions that we need. There's been
16:57
some really healthy dialogue between payers and plan
17:00
plans and providers
17:02
about a lot of the upfront investment to
17:04
really get there
17:06
lands on the plans, and the plans are
17:08
kinda saying,
17:09
I'm willing to make that investment if I'm
17:13
confident that providers,
17:15
you're gonna use this channel
17:17
for electronic prior authorization. It goes back to
17:20
where Rob started us, the the EDI four
17:23
runners, the two seventy eights, and, you know,
17:25
there's the ways that was done before, it
17:28
wasn't utilized.
17:30
So it's a little bit of a chicken
17:32
and egg problem that we have to overcome,
17:35
and I don't think we've quite figured out
17:37
how to turn the dial on that. I
17:39
don't know, Rob. How do you see it?
17:41
Yeah. You know, there's a few, what I
17:43
call,
17:44
drivers that have happened over the last, frankly,
17:47
the last few months.
17:48
One is the June 23 announce announcement
17:52
made by HHS
17:53
where they gathered about 50 of the leading
17:57
health plans in the nation
17:58
to sign a pledge to say they were
18:00
going to support
18:01
these fire APIs for prior authorization.
18:04
That was a tremendous
18:07
shot in the arm, I think, for the
18:09
industry.
18:10
The second
18:11
was and and Steven alluded to it, the
18:13
fact that providers,
18:15
you know, they may be on the fence
18:17
because if they don't have the
18:19
support with their software
18:21
vendors, they're not gonna be able to take
18:23
advantage of this. That in part was solved
18:26
with the release,
18:27
by, ASTP ONC of the HTI four rule,
18:31
which requires
18:33
APIs to be embedded
18:35
into
18:36
the EHR certification
18:38
program
18:39
and
18:40
adherence to,
18:42
one version of the implementation
18:45
guide.
18:46
So a big, big change there. The other
18:48
piece,
18:49
which is more on the horizon,
18:52
is this week,
18:54
the what's called the unified agenda was
18:57
published, which is the regulatory
18:59
blueprint for the federal government.
19:02
Included in that was,
19:04
a proposed rule that to include drugs
19:08
in the zero zero five
19:11
seven rule because drugs were excluded
19:14
in the final rule,
19:16
and providers, you know, lament that
19:18
many of the prior authorizations
19:20
revolve around,
19:22
around drugs. So to include that, perhaps not
19:25
right away, but down the road, again,
19:28
fuels
19:29
fuels the fire and will hopefully encourage
19:32
providers,
19:33
to invest in the technology.
19:35
Well, we'll certainly have to schedule a follow-up
19:37
podcast to discuss all of those again, I
19:39
feel like.
19:40
Well, Robert and and Steven, thanks so much
19:42
for being here. This is fantastic. I I
19:44
wanna turn the floor over to you for
19:46
for some closing remarks here. Anything else that
19:48
we haven't touched on that that you'd like
19:50
to share, before we close? Steven, why don't
19:52
we start with you? Yeah. I got I
19:54
got two thoughts.
19:55
I I think one of the things
19:58
that you talked about a path forward, and
20:01
I actually think
20:02
kind of the fact that
20:05
the regulation doesn't try to stip doesn't try
20:08
to cross every t and dot every I.
20:10
So we've got this nice setup now where
20:13
we have a regulation that says there's certain
20:15
things that must be in place by one
20:17
one '27.
20:18
We highly recommend that the right way to
20:20
do this
20:22
is through these DaVinci burden reduction
20:24
IGs. That's the longer term road map, but
20:27
there's tremendous wiggle room in terms of how
20:30
do you get from what has to be
20:32
in place on one one twenty seven to
20:34
doing everything we wanna do via the burden
20:37
reduction IGs. And I think one of the
20:40
things that we're spending a lot of times
20:41
working with clients on is not letting the
20:44
perfect be the enemy of the good. We're
20:46
talking a lot with their providers in terms
20:48
of what are your workflows. What do you
20:50
actually need upfront
20:51
to wanna start walking this path? And what
20:54
is it what is okay
20:56
if we start to suss that in over
20:58
time? So I think that's something I really
21:00
encourage everybody to do. If you're a plan,
21:03
talk with your provider network. If you're a
21:05
providers, talk with your plans. Can we try
21:07
to collectively not let the perfect be the
21:10
enemy of the good? As Rob likes to
21:12
say, we need a glide path to perfection,
21:15
and I think it makes it a lot
21:16
more doable. And the last thing I'll say
21:19
is,
21:20
my gosh,
21:22
if,
21:23
if before my career is over, if I
21:25
can just be a small part
21:27
of transforming
21:29
EPA,
21:29
so it excuse me, prior authorization,
21:32
so it is
21:34
seamless.
21:36
I'll feel like, I I I had a
21:38
small part in something really big, and I
21:40
hope everybody feels that way. I'm hopeful we'll
21:43
get there. Robert, go ahead. Any last thoughts
21:45
there? Yeah.
21:46
Yeah. Agree with everything,
21:48
Steven said. I'll add two things. One, the
21:51
old adage, it takes a village.
21:54
The only way for the industry to move
21:56
forward is to do it together. We have
21:58
to share
22:00
the pain and share the the the success.
22:03
We we have to educate ourselves on how
22:06
to do this. There this is brand new
22:09
technology for health care, and so I think
22:12
we need to work
22:14
together.
22:15
The second is,
22:17
I love the idea of
22:19
of the glide path and the glide path
22:21
being even beyond
22:23
prior authorization.
22:25
I think this echoes,
22:27
the the or has the potential
22:29
of being a revolution
22:31
in how,
22:32
payers and providers exchange
22:34
data in all ways.
22:37
The the third quick point is, you know,
22:40
the other, of approaches,
22:42
are probably not going away, but what what
22:45
we need to do is prove the value,
22:47
and and that will drive everybody to move,
22:51
forward.
22:52
Well, Steven and Robert, again, thank you so
22:54
much for being here. Such great insights. And,
22:56
again, we'll have to do this again. There's
22:57
so much, moving so many moving parts that
23:00
I feel like in a couple months, we'll
23:01
have to meet again
23:02
and discuss this again. Again, thank you all
23:05
for being here. We also want to thank
23:06
our podcast sponsor inner systems. You can tune
23:09
into more podcasts from Becker's healthcare by visiting
23:11
our podcast page at becker'shospitalreview.com.