In part 1 of our 2-part series on recently introduced legislation that would streamline the prior authorization process for Medicare Advantage (MA) plans, we discussed the impact of electronic prior authorization (ePA) on improving patients’ timely access to care using metrics like time to resolution and approval rate. In this article, we will examine whether these metrics sufficiently address patient access and provider experience when published annually, as required by Improving Seniors’ Timely Access to Care Act of 2021, and identify what metrics should be published and at what frequency to truly impact patient access.
To begin, let’s look at “percentage of requests approved” — what can this metric tell us about patient access and the provider experience? If segmented by drug class or specific treatment, this metric may shed light on utilization management practices that place a higher burden on the provider to justify use of a specific class of drugs or a specific product due to its risk/benefit profile, cost, or some other factor. Relatedly, this metric may also speak to how well practices understand the requirements of MA plans for a specific prior authorization. Additional metrics such as percentage of prior authorizations denied and percentage of prior authorizations with modified approval would help further illuminate nuances related to the provider experience.
Average response time for prior authorizations is a metric that directly relates to patient experience. Delays to treatment caused by administrative processes add undue stress to patients and their families at a time when they are already dealing with the anxiety and uncertainty of unknown medical symptoms or a new medical diagnosis. While average response time is a good starting metric, SamaCare has found that the mean response time does not accurately depict the prior authorization resolution curve for many drugs. In previous articles, we have discussed the concept of “wayward prior authorizations,” that is, prior authorizations that are not immediately resolved (in one day or less). In a study SamaCare conducted based on prior authorization data for physician-administered drugs in the spring of 2020, we found that for wayward prior authorizations the average time to resolution jumps to 9.5 days. Based on our data, wayward prior authorizations are 69% more likely to delay a provider’s intended date of service for a patient, negatively impacting the patient experience. Based on our learnings, we recommend MA plans publish not only average response times, but also quartiles for response times to more accurately depict the provider experience prescribing a drug and the patient experience accessing critically important treatments.
Lastly, let’s consider whether annual metrics are sufficient to understand provider experience and patient access. SamaCare analyzed the average time to resolution, by month, for all retina related prior authorizations across our platform in 2020. We found that the monthly average ranged over +/- 2 days from the busiest time of year to the least busy time of year, indicating seasonality can substantially impact prior authorization efficiency — likely, on both the provider and payer ends of the process. One substantial value of digitizing prior authorizations, a requirement of the Improving Seniors’ Timely Access to Care Act of 2021, is the ability to derive near real-time data leveraging the automation and unification that is possible through electronic prior authorizations.
In part 1 of our 2-part series on recently introduced legislation that would streamline the prior authorization process for Medicare Advantage (MA) plans, we discussed the impact of electronic prior authorization (ePA) on improving patients’ timely access to care using metrics like time to resolution and approval rate. In this article, we will examine whether these metrics sufficiently address patient access and provider experience when published annually, as required by Improving Seniors’ Timely Access to Care Act of 2021, and identify what metrics should be published and at what frequency to truly impact patient access.
To begin, let’s look at “percentage of requests approved” — what can this metric tell us about patient access and the provider experience? If segmented by drug class or specific treatment, this metric may shed light on utilization management practices that place a higher burden on the provider to justify use of a specific class of drugs or a specific product due to its risk/benefit profile, cost, or some other factor. Relatedly, this metric may also speak to how well practices understand the requirements of MA plans for a specific prior authorization. Additional metrics such as percentage of prior authorizations denied and percentage of prior authorizations with modified approval would help further illuminate nuances related to the provider experience.
Average response time for prior authorizations is a metric that directly relates to patient experience. Delays to treatment caused by administrative processes add undue stress to patients and their families at a time when they are already dealing with the anxiety and uncertainty of unknown medical symptoms or a new medical diagnosis. While average response time is a good starting metric, SamaCare has found that the mean response time does not accurately depict the prior authorization resolution curve for many drugs. In previous articles, we have discussed the concept of “wayward prior authorizations,” that is, prior authorizations that are not immediately resolved (in one day or less). In a study SamaCare conducted based on prior authorization data for physician-administered drugs in the spring of 2020, we found that for wayward prior authorizations the average time to resolution jumps to 9.5 days. Based on our data, wayward prior authorizations are 69% more likely to delay a provider’s intended date of service for a patient, negatively impacting the patient experience. Based on our learnings, we recommend MA plans publish not only average response times, but also quartiles for response times to more accurately depict the provider experience prescribing a drug and the patient experience accessing critically important treatments.
Lastly, let’s consider whether annual metrics are sufficient to understand provider experience and patient access. SamaCare analyzed the average time to resolution, by month, for all retina related prior authorizations across our platform in 2020. We found that the monthly average ranged over +/- 2 days from the busiest time of year to the least busy time of year, indicating seasonality can substantially impact prior authorization efficiency — likely, on both the provider and payer ends of the process. One substantial value of digitizing prior authorizations, a requirement of the Improving Seniors’ Timely Access to Care Act of 2021, is the ability to derive near real-time data leveraging the automation and unification that is possible through electronic prior authorizations.
In part 1 of our 2-part series on recently introduced legislation that would streamline the prior authorization process for Medicare Advantage (MA) plans, we discussed the impact of electronic prior authorization (ePA) on improving patients’ timely access to care using metrics like time to resolution and approval rate. In this article, we will examine whether these metrics sufficiently address patient access and provider experience when published annually, as required by Improving Seniors’ Timely Access to Care Act of 2021, and identify what metrics should be published and at what frequency to truly impact patient access.
To begin, let’s look at “percentage of requests approved” — what can this metric tell us about patient access and the provider experience? If segmented by drug class or specific treatment, this metric may shed light on utilization management practices that place a higher burden on the provider to justify use of a specific class of drugs or a specific product due to its risk/benefit profile, cost, or some other factor. Relatedly, this metric may also speak to how well practices understand the requirements of MA plans for a specific prior authorization. Additional metrics such as percentage of prior authorizations denied and percentage of prior authorizations with modified approval would help further illuminate nuances related to the provider experience.
Average response time for prior authorizations is a metric that directly relates to patient experience. Delays to treatment caused by administrative processes add undue stress to patients and their families at a time when they are already dealing with the anxiety and uncertainty of unknown medical symptoms or a new medical diagnosis. While average response time is a good starting metric, SamaCare has found that the mean response time does not accurately depict the prior authorization resolution curve for many drugs. In previous articles, we have discussed the concept of “wayward prior authorizations,” that is, prior authorizations that are not immediately resolved (in one day or less). In a study SamaCare conducted based on prior authorization data for physician-administered drugs in the spring of 2020, we found that for wayward prior authorizations the average time to resolution jumps to 9.5 days. Based on our data, wayward prior authorizations are 69% more likely to delay a provider’s intended date of service for a patient, negatively impacting the patient experience. Based on our learnings, we recommend MA plans publish not only average response times, but also quartiles for response times to more accurately depict the provider experience prescribing a drug and the patient experience accessing critically important treatments.
Lastly, let’s consider whether annual metrics are sufficient to understand provider experience and patient access. SamaCare analyzed the average time to resolution, by month, for all retina related prior authorizations across our platform in 2020. We found that the monthly average ranged over +/- 2 days from the busiest time of year to the least busy time of year, indicating seasonality can substantially impact prior authorization efficiency — likely, on both the provider and payer ends of the process. One substantial value of digitizing prior authorizations, a requirement of the Improving Seniors’ Timely Access to Care Act of 2021, is the ability to derive near real-time data leveraging the automation and unification that is possible through electronic prior authorizations.
In part 1 of our 2-part series on recently introduced legislation that would streamline the prior authorization process for Medicare Advantage (MA) plans, we discussed the impact of electronic prior authorization (ePA) on improving patients’ timely access to care using metrics like time to resolution and approval rate. In this article, we will examine whether these metrics sufficiently address patient access and provider experience when published annually, as required by Improving Seniors’ Timely Access to Care Act of 2021, and identify what metrics should be published and at what frequency to truly impact patient access.
To begin, let’s look at “percentage of requests approved” — what can this metric tell us about patient access and the provider experience? If segmented by drug class or specific treatment, this metric may shed light on utilization management practices that place a higher burden on the provider to justify use of a specific class of drugs or a specific product due to its risk/benefit profile, cost, or some other factor. Relatedly, this metric may also speak to how well practices understand the requirements of MA plans for a specific prior authorization. Additional metrics such as percentage of prior authorizations denied and percentage of prior authorizations with modified approval would help further illuminate nuances related to the provider experience.
Average response time for prior authorizations is a metric that directly relates to patient experience. Delays to treatment caused by administrative processes add undue stress to patients and their families at a time when they are already dealing with the anxiety and uncertainty of unknown medical symptoms or a new medical diagnosis. While average response time is a good starting metric, SamaCare has found that the mean response time does not accurately depict the prior authorization resolution curve for many drugs. In previous articles, we have discussed the concept of “wayward prior authorizations,” that is, prior authorizations that are not immediately resolved (in one day or less). In a study SamaCare conducted based on prior authorization data for physician-administered drugs in the spring of 2020, we found that for wayward prior authorizations the average time to resolution jumps to 9.5 days. Based on our data, wayward prior authorizations are 69% more likely to delay a provider’s intended date of service for a patient, negatively impacting the patient experience. Based on our learnings, we recommend MA plans publish not only average response times, but also quartiles for response times to more accurately depict the provider experience prescribing a drug and the patient experience accessing critically important treatments.
Lastly, let’s consider whether annual metrics are sufficient to understand provider experience and patient access. SamaCare analyzed the average time to resolution, by month, for all retina related prior authorizations across our platform in 2020. We found that the monthly average ranged over +/- 2 days from the busiest time of year to the least busy time of year, indicating seasonality can substantially impact prior authorization efficiency — likely, on both the provider and payer ends of the process. One substantial value of digitizing prior authorizations, a requirement of the Improving Seniors’ Timely Access to Care Act of 2021, is the ability to derive near real-time data leveraging the automation and unification that is possible through electronic prior authorizations.
