Every American deserves access to affordable, high-quality coverage and care. But too many of our nation’s health care dollars are wasted through unnecessary, inappropriate, or even harmful care. Even doctors agree: 65% of physicians have said that at least 15-30% of medical care is unnecessary. This is unacceptable, particularly when combined with the fact that too many Americans struggle to access health care that is affordable.
Prior authorization (PA) is essential to support patient access to clinically appropriate, evidence-based care. Prior authorization can reduce inappropriate care for patients by catching unsafe or low-value care or care that is not consistent with the latest clinical evidence before it occurs – all of which contribute to unnecessary costs and potential harm to patients. Public and private purchasers of health care recognize the value of this essential tool.
While PA is critical in reducing unsafe, low-value, or inappropriate care, the process can be burdensome to providers, patients, and health insurance providers alike, especially when working on an outdated, manual, paper-based system. In 2018, stakeholders representing providers, insurers, and pharmacists developed a Consensus Statement recommending opportunities to improve the PA process.
Increasing the adoption of electronic prior authorization (ePA) was one of the major opportunities identified for improving the PA process. Using health information technology to exchange data has been demonstrated to improve health outcomes, enhance efficiencies, and reduce costs. Despite this opportunity, physicians, however, are lagging in their adoption of electronic health data exchange, including ePA. According to a recent study published by the Office of the National Coordinator for Health Information Technology (ONC), about one-third (35%) of office-based physicians still used only fax, mail, or e-fax to share patient health information with providers outside of their organization in 2019. In addition, physicians’ engagement in electronically sending, receiving, and integrating information did not change between 2015 and 2019.