A world without prior authorization — How analytics are helping health systems transition to value-based care 

In healthcare's current fee-for-service landscape, it might be difficult to imagine a world without prior authorizations. But as more hospitals and payers shift to value-based care contracting and embrace analytical data-sharing, the burdens and inefficiencies associated with the prior authorization process may become a thing of the past. 

How healthcare advances to this new reality was discussed in a March 25 webinar, hosted by Becker's Hospital Review and sponsored by CareJourney, featuring: 

  • Rod Neill, COO at Mercy Health Physicians in Youngstown, Ohio
  • Dianna Grant, MD, CMO at Next Level Health 
  • Mark Foulke, executive vice president of transformational value-based care at Privia Health
  • Greg Kuzma, chief healthcare economics officer at Privia Health
  • Moderated by Aneesh Chopra, president of CareJourney

The U.S. government is rapidly transitioning to value-based payment arrangements with goals to move both traditional Medicare and Medicare Advantage to 100 percent value-based contracts and commercial payers and Medicaid to 50 percent value-based contracts by 2025.

CMS has made it clear that value-based adaptation will be driven by both payers and providers. On the data sharing front, the government is requiring payers and providers to publish standardized data to an application of a consumer’s choice, with payers up first on the new rules by 2021, and provider networks, with their EHR vendors, by 2022. CMS further anticipates health plans negotiating data sharing agreements with their provider networks tied to these standardized formats as it would lower the compliance burden on their end. To demonstrate the viability of these types of data sharing arrangements, CMS has already launched a Data at the Point of Care pilot that allows providers to incorporate claims data directly into EHRs via applications of a provider’s choice, said Mr. Chopra. 

While a world without preauthorizations is still a ways away, successful value-based arrangements are becoming more commonplace. Mr. Neill shared insights into Mercy Health's arrangements, Mr. Kuzma and Mr. Foulke reviewed Privia Health's setup, and Dr. Grant offered insights from the payer perspective. 

Five years ago, Mercy Health Physicians had 4 percent of its revenue tied to value-based care, today, the group is at 23 percent. The origins of this jump can be traced back a decade when the group invested in analytics and created a scorecard. 

"We wanted to hear the voice of our customer and understand what we were doing right," Mr. Neill said. "This isn't something that's only available on a monthly basis. This is something available to our entire organization. We went to full transparency, and the only way you can do that is by building trust." 

Mercy used the data and developed a clinically-integrated network that became part of its ACO. The group implemented a shared leadership program, and made care coordinators and prevention clinics a mainstay of its care sites. But what has been more important is that Mercy embraced its payers. The health system meets with its payers quarterly and openly shares outcomes data. By collaborating together, Mercy and its payers have become more unified and are more likely to enter into value-based contracts.

Privia has experienced similar success. Mr. Foulke attributed a large part of the national physician organization's success to working with its physician partners and payers and being flexible to understand the needs of both parties. When Privia was exploring value-based arrangements, leadership went to physicians to hear their vision for value-based care. They came back with eight guiding principles, of which four have broken out and defined themselves from the rest. 

The Privia physicians wanted: like-minded payer partners, contracts with aligned incentives, a provider compensation model tied to improved quality and lower cost, and physician leadership. While all eight principles are quintessential to the success of Privia's program, the partnership wouldn't have succeeded without payer and physician buy-in. 

Like Mercy, Privia's leadership team meets quarterly with payers to discuss common goals and explore payment arrangements. It's in these meetings that the first steps to a world without prior authorizations are taking place. 

"Our main tool is joint meetings with payers," Mr. Kuzma said. "We get on quarterly, share bidirectional data the things we're seeing with payer arrangements. Overtime, we're going to be able to move towards consistent measures and standards versus what payers have with their legacy systems." 

"When having these conversations with payers we want to show we can handle this," Mr. Foulke said. "Our conversation is tell us what you want and get out of the way, let us do it." 

Getting out of the way and letting clinicians provide care is what Dr. Grant said can be possible. "The EHR and the bidirectional flow of data [can get us there], she said. "When we have groups that share that information with us, the need for prior authorization goes away. … Because we see realtime information, we can see that the patient can get what he or she needs." 

To achieve widespread  value-based care and change healthcare delivery forever, health systems and payers have to embrace data and collaboration.. 

To view a copy of the webinar, click here. 

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