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AHIP Survey: Prior Authorization Grounded In Clinical Evidence And Selectively Used

posted by AHIP

on June 9, 2020

Just like doctors use scientific evidence to determine the safest, most effective treatments, health plans rely on data and evidence to understand what treatments best improve patient health and target prior authorization programs to promote appropriate care. The vast majority of health plans’ prior authorization programs incorporate physician input and design their prior authorization programs with the goals of improving quality and protecting patient safety. That’s according to a recent commercial survey of health plans on prior authorization from America’s Health Insurance Providers (AHIP).

The report found that health plans use multiple sources of evidence-based studies, guidelines and federal standards in designing their prior authorization programs. More specifically, 98% of insurance providers use peer-reviewed evidence-based studies, and 89% use federal studies or guidelines. Below are some additional key takeaways:

  • The vast majority of commercial enrollees (close to 85%) are in plans that limit prior authorization to less than 10% of prescription medications.
  • Over 90% of commercial enrollees are in plans that limit prior authorization to less than 25% of medical services.
  • The vast majority of commercial health plans use input from doctors.
    • 82% of health plans consult specialists as needed.
    • 70% use provider-developed clinical guidelines.
  • The primary goals of health plans’ prior authorization programs are to improve quality and promote evidence-based care (98%), protect patient safety (91%), and address areas prone to misuse (84%)
  • The vast majority report that their programs have had an overall positive impact on quality of care (91%), affordability (91%) and patient safety (84%).
  • Prior authorization is often part of a broader strategy to improve outcomes
    • The vast majority of commercial health plans (86%) use value-based provider contracts to incentivize doctors to reduce unnecessary tests, treatments and procedures

The majority of health plans are taking steps to streamline the prior authorization process for both prescription medications (91%) and medical services (89%) and a majority (84%) reported that automation of the prior authorization process is the biggest opportunity for improvement. To that end, AHIP recently launched the new Fast Prior Authorization Technology Highway (Fast PATH) – a demonstration project to evaluate the impact of automating the prior authorization process.

The survey was conducted between September and December of 2019, before the nation’s health care system faced significant changes and challenges brought about by the coronavirus (COVID-19).  As elements of the U.S. health care system begin to re-open, AHIP members remain committed to working with providers to streamline the prior authorization process to ensure all patients receive safe, affordable care, evidence-based care at the right time and in the right setting.

Read the full study results and methodology.

Read a one-page infographic highlighting survey results on automating prior authorization.

Read a one-page infographic highlighting survey results on use of prior authorization.

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