Over the next several months, health plans, health systems, policymakers and patients led by Baltimore-based Johns Hopkins will begin addressing prior authorization as part of a convening group.
While the group is meeting for the first time today, it will build upon previous work at Johns Hopkins, including a partnership with Highmark Health and Pittsburgh-based Allegheny Health Network. Multiple Blue Cross Blue Shield plans from across the country have joined the recent initiative.
The program’s co-chairs filled in Becker’s on how experts and patients will focus on this reform.
“We’re really hopeful that this can bring together many people to collaborate across sectors and across disciplines to advance this work,” said Laura Sigman, MD, executive director of strategic solutions with the Armstrong Institute for Patient Safety and Quality and assistant professor of pediatrics. This initiative includes the academic, clinical and health plan branches of Johns Hopkins.
The specific prior authorization workgroup will focus on cardiovascular disease and musculoskeletal pain, which both have clear clinical guidelines.
“We’re focused on consistent, evidence-based rules that adhere to clinical practice guidelines by medical societies — and then automate,” Pamela Johnson, MD, vice president of care transformation and professor of radiology, said.
While gold carding is top of mind for some, automation is the end goal for this workgroup.
“Will a health plan ever trust a clinical decision support tool within the EHR? I don’t know. That is sort of our pipe dream … the doctor sitting there with the patient and ideally they would know right away, ‘This is not going to get approved,'” Dr. Johnson said.
Sharing longitudinal data is one way health plans can contribute to the workgroup.
“We see an opportunity to combine our data sources — because [plans] have longitudinal claims data — to say it’s not just about having the same rules. It’s about identifying areas where we know we can improve outcomes … and then demonstrating the effectiveness of that by collaborating on data collection over time,” Dr. Johnson said.
Aligning health plan incentives and provider and patient needs will be one challenge, Dr. Sigman said, but Dr. Johnson is confident ROI should not be a concern for insurers. Dr. Johnson said that health insurers are often preoccupied with whether they can see an ROI within the first few years of a program because patients may switch plans. However, “if every health plan invested in those same programs, they would all benefit from the ROI.”
“We don’t like to walk away when people say, ‘That won’t work.’ We just want to do the difficult things,” Dr. Johnson added.
