Prior Authorizations for Health Care

On Tuesday, Julia Boles, Health Policy Advisor at Green Mountain Care Board (GMCB), presented a report regarding Prior Authorization (PA) to the Senate Health and Welfare Committee. She explained that “Prior Authorization” means the process used by a health plan to determine the medical necessity, medical appropriateness (or both) of otherwise covered drugs. It is also applied to medical procedures, medical tests, and other health care services. Prior authorization is a process by which a medical provider (or the patient, in some scenarios) must obtain approval from a patient's health plan before moving ahead with a particular treatment, procedure, or medication.

PA requirements vary across health insurance plans based on what the insurance plan covers and insurer-specific clinical guidelines. Health insurance companies use PAs as a cost containment tool and align PA requirements with clinical standards set by each insurance company. Boles shared some of the ways that PAs allow payers, like the Department of Vermont Health Access (DVHA), to effectively manage costs. 

Although PAs are used by payers to effectively manage costs it is also useful as a mechanism to ensure the safety of its members and to prevent imminent harm from occurring, as well as to uphold clearly established standards of care. Prior authorization is also used to ensure adherence to criteria for procedures that are appropriate for very specifically defined clinical conditions, such as low-dose computer tomography (CT) scans for certain types of lung cancer. Other secondary outcomes from the prior authorization process include the discovery of fraud, waste, or abuse, findings of quality-of-care issues, and addressing access issues (such as arranging transportation for out of state care.

The American Medical Association (AMA) has conducted a national survey of physicians about the impact of prior authorization. The AMA also surveys the impact on patients.

Back in 2013, Vermont passed Act 171 directing the GMCB to work with health care professionals and health care insurers to implement a prior authorization pilot program. The Legislature passed Act 140 which required Gold Carding pilot programs for insurers. Gold Carding refers to the practice of exempting providers from seeking prior authorization of a service if they have an acceptable approval rating (using evidence-based guidelines) over a specified time period.

She discussed the GMCB Primary Care Advisory Group PA recommendations from 2018, which eliminated prior authorization for Vermont primary care providers (PCPs), with specific guidelines. The current reporting on PAs includes all Vermont-licensed health insurers. The reporting provides aggregate information about the number of PAs by category, the denial rates, and appeals, which is helpful to understand the overall landscape of PAs for health insurers, and is available to the public.

Boles moved on to review Act 183, which aligned reporting, including real-rime PA and clinical data from the Veterans Health Information Exchange (VHIE). Approximately 36% of requests could be approved using VHIE data, but it not being used due to deficiencies in data reporting, as opposed to legal or technological limitations with the data set. She compared it with the Act 152 reporting. There are plans to incorporate public health data such as immunizations and other vital records into the VHIE.

The Centers for Medicare and Medicare Services (CMS) has proposed rules that would require payers maintain a provider access application programming interface (API) to automate the process for determining whether a PA is required, identify documentation requirements, and ease the exchange of PA requests and decisions from electronic health record (EHR) systems. She also reviewed opportunities to increase the utility of VHIE data to support PA requests.

Boles noted that no states currently require insurers to submit their PA requirements to state regulators in a uniform format. The federal government does not collect any PA information and it does not have a standardized format for PA language. For various reasons, Act 183 did not mandate an ongoing reporting requirement, but she discussed items that insurers would be required to submit if such a system were implemented.

Opportunities for Legislative action that she pointed to included expanding the Gold Carding programs to exempt providers from PAs for certain services. Additional opportunities include decreasing the timeframe for health insurers to respond to PA requests, limiting how insurers apply step therapy protocols for prescription drugs, improve quality and quantity of clinical data in the VHIE, and to consider prohibiting insurers from requiring reauthorization during the current plan year for preventive services.

After further review the Senate Health and Welfare Committee will make decisions regarding Act 183 and PAs "at a later time."

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