Docs Blame Increasing Regulatory Burdens For “What’s Ailing” Their Practices

When the Medical Group Management Association recently asked its members about some of the regulatory burdens they’ve experienced, one question was about the Stark Law Anti-Kickback statute. Formally known as the Physician Self-Referral Act, it prevents doctors from referring patients in whom there are financial interests or investments.

The law itself appears cut-and-dried, though like many regulations, there are complexities attached. There were two slight extremes in MGMA’s  survey results: At least 15 percent of the MGMA’s 425 medical group practices who filled out its survey said they had no problem with the regulation, saying it was not burdensome. Yet, at least 32 percent said it was extremely burdensome.

Depending on someone’s view, the regulations involving the Stark Act may appear to be troubling – with at least one-third of the doctors seeing it that way.

But there’s another pressing issue that the results showed. Of all the questions about regulations that the MGMA posed, the one about the Stark Act showed a response that basically said:

Hey, this is an easy regulation.

Indeed, MGMA’s members found other regulations far – far – worse than the Stark Act.

Overall, the medical groups say that wasteful regulatory burdens are driving up too many costs and generating too much of their time that they say could be better spent on patient care. In some cases, the regulations continued to worsen over the past year.

Regulatory Issues

When asked in the survey about “how burdensome would you rate each of the following applicable regulatory issues,” the respondents were overwhelming in saying they were either “very or extremely burdensome:”

The worst — Medicare Quality Payment Program (MIPS/APMs) – 88 percent. MGMA officials said that “ranked as the most burdensome issue” and “little clinical benefit.”

Others:

  • Prior Authorization – 82 percent.
  • Lack of electronic health record “interoperability.”– 80 percent.
  • Government EHR requirements – 77 percent.
  • Audits and appeals – 68 percent.

 Survey Findings

The findings were included in the so-called 2018 Regulatory Burden Survey at MGMA18, the annual conference. MGMA includes 40,000 medical practice administrators, executives and healthcare leaders. The organization says it represents more than 12,500 organizations that deliver almost half of the healthcare in the U.S.

  • A vast majority – 86 percent – of respondents “reported the overall regulatory burden on their medical practices has increased over the past 12 months,” MGMA said. Even more respondents – 94 percent – agree that a “reduction in regulatory burden” would allow their practices to reallocate resources toward patient care, according to the organization.

“This precipitous increase in regulatory burden over the past 12 months should alarm policymakers,” said Anders Gilberg, senior vice president of federal affairs. “MGMA’s survey provides valuable insight into what’s ailing medical practices.”

What’s ahead?

As healthcare moves toward value-based payment, a “staggering 90 percent” of those surveyed reported that it resulted regulatory burden increases on their practices, MGMA said. And 76 percent said it did not improve the quality of care delivered to patients.

As far as the doctors see it, the regulations rumble ahead.

Gilberg has hope. He says MGMA’s findings “will enable HHS (Health and Human Services) to refocus and redouble its efforts to create meaningful regulatory relief for physician practices.” — Joe Cantlupe

 

Study: Poring Cold Water On Your Beer (or Wine…) And Bingers?….Slow Down

While there have been conflicting reports over the years about how much alcohol someone could drink and maintain good health, a recent study pores cold water on that: No alcohol is good for you, it says.

That could be an eye-opener for a lot of people. At least one third of the people around the world drink alcohol at some time, for social events, or celebrations, or part of a dining experience, whether having beer or wine or liquor.

The latest study  in Lancet says there is growing evidence that people should not drink alcohol at all because it is unhealthy. Alcohol contributes to 2.8 million deaths a year worldwide, and is the leading risk factor for disease and premature death in men and women between the ages of 15 and 49 in 2016, the study says.

The study contradicts previous reports, even touted by major U.S. organizations, in which public officials said moderate drinking, such as having two per day for men, or one for women, would be ok. Such advice is included in the Dietary Guidelines for Americans, and supported by the American Heart Association and the American Cancer Society. The Dietary Guidelines for Americans also do not recommend that individuals who do not drink alcohol start drinking for any reason.

What is the risk? 

For women, low-risk drinking is defined as no more than 3 drinks on any single day and no more than seven drinks per week, according to the U.S. government. For men, it is defined as no more than four  drinks on any single day, and no more than 14 drinks per week.

The latest Lancet study about drinking not only upsets many habits but millions of dollars in industry.  The analysis included those of hundreds of studies about drinking from 1990 to 2016.

According to the 2015 National Survey on Drug Use and Health, 86.4 percent of people ages 18 or older reported that they drank alcohol at some point in their lifetime: 70.1 percent reported that they drank in the past year; 56 percent reported that they drank in the past month.

An estimated 88,000 people die from alcohol-related causes annually, making alcohol the third leading preventable cause of death in the United States. The first is tobacco, and the second is poor diet and physical inactivity, according to the  National Institute on Alcohol Abuse and Alcoholism. 

Accidents and Disease

The deaths stem from alcohol-related cancer and cardiovascular diseases, infectious diseases, such as tuberculosis, intentional injury such as violence and self-harm and traffic accidents and other unintentional injuries such as drowning and fires. Alcohol consumption is also associated with a variety of short and long term health risks, including motor vehicle crashes, violence, sexual risk behaviors, high blood pressure and various cancers. The risk of harm increases as the amount of alcohol you drink, researchers say.

 Surprising Findings

Among the reports for years that said moderate drinking was OK, included studies that said alcohol could even protect against heart disease, but the latest study shows that it is outweighed by the problems it causes.

“The most surprising finding was that even small amounts of alcohol use contribute to health issues globally. We’re used to hearing that a drink or two a day is fine, but the evidence is evidence,” says senior study author Emmanuela Gakidou, professor of the University of Washington Institute for Health Metrics and Evaluation.

Due to their population sizes, China, India and Russia led the world in total number of alcohol related deaths in men and women. The U.S. ranked fifth among men and seven among women on that list, the UK ranked 21st for men and ninth for women.

Binge Drinking

For too many people in the U.S., they don’t drink moderate amounts of alcohol, but simply drink too much. A separate Centers for Disease Control and Prevention study shows increased health problems such as injuries, violence, liver diseases and cancer, are linked to “binge” drinking.

Binge drinking means having five or more drinks on an occasion for men, and four or more drinks on an occasion for women, during a two-hour period. CDC researchers found that one in six or 37 million people adults binge drink about once a week, consuming an average of seven drinks per binge.

In a March study, U.S adults consumed more than 17 billion binge drinks in 2015 or about 470 binge drinks per drinker, according to the CDC.

“This study shows that binge drinkers are consuming a huge number of drinks per year, greatly increasing their chances of harming themselves and others,” said Study coauthor Robert Brewer, MD, MSPH, lead researcher in CDCs alcohol program.

About two-thirds of people – 66.6 percent – age 12 and older reported in 2014 that they drank alcohol within the past 12 months, with 6.4 percent meeting the criteria for an alcohol use disorder, according to SAMSHA’s National Survey on Drug Use and Health (NSDUH) – 2014.

Alcoholism

 study published in JAMA Psychiatry this month found that the rate of alcohol use disorder, or “alcoholism,” rose by 49 percent in the first decade of the 2000s. That means one in eight American adults, or 12.7 percent of the U.S. population. — Joe Cantlupe

REFERENCES:

Wood, A, Kaptoge, Butterworth, et al. Risk threshold for alcohol consumption: combined analysis of individual -participant data for 599 912 current drinkers in 83 prospective studies. The Lancet. 2018. Vol. 391. Issue 10129, P1513-1523, April 14, 2018. DOI: /10.1016/SO140-6736(1)30134-

Medicine Net. Alcohol Helps Kill 2.8 Million People Globally Each Year. Retrieved from:

https://www.medicinenet.com/script/main/art.asp?articlekey=214800&ecd=mnl_day_082418

Sandee LaMotte. CNN. 2018. No amount of alcohol is good for your overall health, global study says. Retrieved from: https://www.cnn.com/2018/08/23/health/global-alcohol-study/index.html

Jamie Ducharme. Time. 2018. A New Study Says Any Amount of Drinking Is Bad for You. Here’s What Experts Say. Retrieved from: http://time.com/5376552/how-much-alcohol-to-drink-study/

Fact Sheets-Moderate Drinking. Centers for Disease Control and Prevention. Retrieved from: https://www.cdc.gov/alcohol/fact-sheets/moderate-drinking.htm

CDC Newsroom: During binges, U.S. adults have 17 billion drinks a year. Retrieved from:

https://www.cdc.gov/media/releases/2018/p0316-binge-drinking.html

https://www.pacificcollege.edu/news/blog/2015/03/15/rough-road-alcoholism-and-how-chinese-medicine-can-help%E2%80%A6

 Substance Abuse and Mental Health Administration. Alcohol, Tobacco and Other Drugs. Retrieved from: https://www.samhsa.gov/atod

National Institute on Alcohol Abuse and Alcoholism: Alcohol Facts and Statistics. Retrieved from: https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/alcohol-facts-and-statistics

https://jamanetwork.com/journals/jamapsychiatry

The National Academies of Sciences: “Unacceptable” Food Waste in U.S.

In millions of households, restaurants and other locations across the United States, food is discarded, lost or wasted.

Elsewhere in the country, about one in eight people struggle with hunger and simply want something to eat, even though the world is producing enough food.

The dichotomy is great. The National Academies of Sciences  states that more than one third of the food produced in the U.S. is unconsumed – an “unacceptable loss of food and nutrients” at a time of heightened global food demand. That one-third amount of food lost or wasted applies to the world as well.

There are fruits and vegetables, plus roots and tubers, seeds, meat and root crops wasted or lost. And that doesn’t just occur from kitchen to trash. The problem “extends throughout the supply chain, from the initial agricultural production to final household consumption,” and amounts to 1.3 billion tons a year, says Food and Agriculture Organization of the United Nations. 

Food Loss and Waste

There’s a difference between food loss and food waste. According to the FAO, bananas that fall off a truck, for instance, is considered food loss. But if a food is fit for human consumption but is not eaten, that’s waste.

Those food losses and waste are among the growing food challenges, never mind the obstacles to get food at all: weather, floods, and drought.

Looking to the Future

But the NAS is looking beyond the natural into the intellectual space: the need for greater advances that uses data sciences, technology, behavioral sciences, and economics, it says.

The NAS identifies what it calls the most promising scientific breakthroughs that are possible to achieve by 2030 that, it said, would increase U.S. food and agricultural industry’s sustainability, competitiveness and resilience.

Recommendations

NAS envisions and calls for scenarios in which soil and crop sensors could provide continuous data that feed and alert a farmer about moisture content not only for an area but for a specific group of plants, “eliminating the need” to irrigate an entire field. It foresees gene editing to accelerate breeding in microbes, plants and animals, or crops that could be effectively modified to improve taste and nutritional value.  Gene editing refers to a technique in which researchers can control traits of certain plants by removing some DNA.

The country, and the world, has no choice but to promptly re-examine and step up its innovations to maintain a food supply, as NAS sees it.

Need Changes

“In the coming decade, the stresses on the U.S. food agricultural enterprise won’t be solved by business as usual – either in the field or in our current research efforts,” said Susan Wessler, Neil and Rochelle Campbell Presidential Chair for Innovations in Science Education, and co-chair of the committee that conducted the study and wrote the recent report.

High Technology

The NAS says developing highly sensitive, field deployable sensors and biosensors will enable rapid detection and monitoring capabilities across various food and agricultural disciplines.

Applying integrated data sciences, software tools and system models will enable advanced analytics for managing the food and agricultural system, the NAS says. NAS officials call for establishing an initiative to exploit the use of genomics and precision breeding to genetically improve traits of agriculturally important organisms.

“Understanding the relevance of the microbiome to agriculture and harnessing the knowledge will improve crop production, transform feed efficiency and increase resilience to stress and disease,” the NAS says.  Microbiome refers to the micro-organisms in the living environment.

Through gene editing, and other techniques, steps can be made to thwart some of the food loss and waste.

“Incorporating essential micronutrients or other quality-related traits in crops through gene-editing tools offers an opportunity to increase food quality and shelf life, enhance nutrition and decrease food loss and food waste,” says NAS’s  pre-publication report. 

Current Gaps

While there have been advances in agriculture techniques and through technology, much more needs to be done, NAS says.

“The food and agricultural system collects an enormous amount of data, but has not had the right tools to use it effectively,” the report says. “Data generated in research laboratories and in the field have been maintained in an unconnected manner.”

Evolving sensing technology also is important and not quite where it should be right now, it says.  Sensing technology refers to the practice of using a device to measure different environmental elements, ranging from heat to motion to light.

“Sensing technology has been used widely in food and agriculture to provide point measurements for a characteristic of interest, such as temperature, but the ability to continuously monitor several characteristics at once is the key to understanding both what is happening in the target system and how it is occurring,” according to the report.

NAS recommends initiatives that should be created “to more effectively develop and employ sensing technologies across all areas of food and agriculture.”

The committee’s other co-chair, John Floros, president of New Mexico State University, said, “Realizing the vision this report recommends will require a holistic approach that combines scientific discovery, technological innovation and incentives to revolutionize the way we approach greater food security and human and environmental health.”

The group concedes that it may be necessary for significant public and private investment to accomplish the plans.

“The food system of tomorrow will depend on how well we are able to prepare for resiliency today and how well we are able to build our capacity for the future,” the report says. — Joe Cantlupe

(from my piece at HCPnow)

REFERENCES:

http://www.fao.org/food-loss-and-food-waste/en/

https://www.fhfh.org/hunger-in-america.html?gclid=CjwKCAjwns_bBRBCEiwA7AVGHkEyRtYlPUcL_PfLAOFKYdocSChpLIl4NNSb8-jNjcWc1wZ9vSxrSxoC76kQAvD_BwE

http://www.nasonline.org/news-and-multimedia/

http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=25059

What was your stomach ‘thinking?’

Scientists talk about what they term the “second brain” in the body.

Excuse me?

Researchers are examining the link between the brain and digestion system, and how the gastrointestinal system specifically can influence the central nervous system. So when people say it’s a “gut feeling” they are speaking more than a cliché.

That can be especially surprising when a person experiences feeling sick to their stomach because it may not be simply the result of a physical ailment. The problem may be related to emotions, or feelings such as anxiety or depression that spur symptoms in the gut.

Psychological factors influence the actual makeup of the gut, and contribute to such conditions as irritable bowel syndrome, or digestive inflammations or make someone susceptible to infection.

The brain-and-gut combination is increasingly becoming a focus of medical study as researchers explore mood and digestion, and the impacts that can result depending on the food you put into your body.

The examination of two key areas of the body reflect much of the approaches of Chinese medicine as well as specialists in herbs, wellness and acupuncture. They have the holistic view of the human body, examining both the brain and gut as part of the whole, not as separate parts.

Neurology and the Gut

The nervous system impacts the gut through the enteric nervous system (ENT). The interesting thing is that although neurons go through the ENT, it operates on its own, hence the name “second brain.”  The ENT, within the gastrointestinal system, can operate independently of the brain and the spinal cord, researchers say. The ENT is comprised of two thin layers of more than 100 million nerve cells that line the gastrointestinal tract, from your throat on down.

The ENT can communicate with the central nervous system through other nerves, but can still function on its own, and it actually relays information to the brain. breaks down certain food, and helps absorb nutrients or eliminating them.

Understanding the ENT connection is important because mind-body therapies can have an impact on bowel-disorder treatments. And there is another link, too, because experts say a higher than normal percentage of people with IBS and other related problems develop depression and anxiety.

The signal could sometimes act like an amber or red traffic light – giving a cue to stop eating certain foods. If you feel a little “off” after certain food, the ENS may be reacting to food you ate, and send the signal to the brain.

Getting the Gut Healthy

There is a bacterial population that lives in the intestines called gut microbiota, and there are good bacteria and bad bacteria. There are tens of trillions of microorganisms and people are affected differently. Much of the bacteria we acquire during birth, and the gut microbiome also has an influence on your emotions, through the “brain-gut” connection.

Changes in the gut microbiomes also can impact the brain, and you can have resultant chronic inflammation, stress, or chronic inflammation from “bad” bacteria. The good bacteria have a contrary impact, such as assisting the immune system.

Researchers have said that when there is an imbalance between good and bad bacteria, it can result in disorders including irritable bowel disease, obesity, cancer, and arthritis.

Probiotic Activity.

Probiotic bacteria, called Lactobacillus rhamnosus, contains a neurotransmitter called GABA that helps regulate brain activity and can thwart anxiety, according to the National Center for Complementary and Integrative Health. Changing the make up of bacteria in the gut “through specific diets” may help to treat stress-related and neurodevelopmental disorders, including autism and hyperactivity, the NCCIH says.

Bad and Good Foods for the Gut

Some foods simply can cause problems and illness going through the body, and are responsible for chronic inflammatory conditions and other issues, depending on the person.

Some of the foods that could cause difficulties are processed foods, red meat, sugar, high fructose corn syrup, gluten, dairy, high sugar and carbohydrate diets.

Leaky Gut

When the brain’s protective barriers that insulate it from harmful substances is somewhat broken because of irritating foods or infections that create what is known as a leaky gut. The leaky guts can release antibodies that allow harmful substances into the brain. That can be one of the main factors behind autoimmune and chronic inflammatory conditions.

Eating Better

Researchers say that changing the bacterial makeup in the gut through different diets may help to treat stress-related and neurodevelopment disorders.  People should eat several servings – as many as five – of fruits and vegetables each day to help the good bacteria, and diminish the bad bacteria.

Happy Gut, Happy Person

An overwhelming number – 90 percent – of serotonin is stored in the gut.  Serotonin, sometimes called the happy chemical because it is linked to happiness, is a chemical found in the brain and bowels that send messages among nerve cells. Keeping this and other so-called neurotransmitters in the gastrointestinal tract healthy are vital for the brain, too.

— Joe Cantlupe …from my piece at HCPnow.

References:

https://www.redbookmag.com/body/healthy-eating/advice/g2395/bad-foods-for-gut-health/

https://justinhealth.com/a-five-step-to-healing-leaky-gut/

https://nccih.nih.gov/news/events/IMlectures/gut-brain

https://medium.com/@drbradysalcido/how-your-gut-influences-your-brain-841173517673

https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/for-healthy-gut-feed-good-bugs/art-20322495

https://www.medicalnewstoday.com/kc/serotonin-facts-232248

https://www.hopkinsmedicine.org/health/healthy_aging/healthy_body/the-brain-gut-connection

https://courses.lumenlearning.com/boundless-ap/chapter/nervous-system-of-the-digestive-system/

https://www.ncbi.nlm.nih.gov/pubmed/19253310

Homeopathy: Health Thyself, says FDA. We’re Not The Problem, say Practitioners.

Homeopathy is an alternative medical practice developed centuries ago that contends substances that effectively cause illness symptoms in otherwise healthy people can actually be used in diluted form to treat illness. And the more diluted it is, the more potent it may be.

That’s the view of the U.S. Food and Drug Administration, which is now at loggerheads with the $3 billion homeopathic industry and is trying to impose regulations on it.  The homeopathic industry has opposed the FDA plans.

The FDA has proposed boosting enforcement of the manufacturing, marketing and safety regulations of homeopathic products, which have been produced since the 1800s.  Homeopathic drug products are prepared from a variety of sources, including plants, minerals, chemicals and human and animal excretions or secretions. They are sold in pharmacies, retail stores and online.

Homeopath professionals see the body as a holistic system working to heal itself. The medications used work to stimulate the healing process, its proponents say.

That is opposed to naturopathy, often in Chinese medicine, in which practitioners work to discover the root causes of illnesses and eliminate them through elements such as supplements and food to balance the body.

Under the law, homeopathic drug products are subject to the same requirements related to approval, adulteration and misbranding as any other drug product, the FDA says. But prescription and nonprescription drug products labeled as homeopathic have been manufactured and distributed without agency approval since 1988.

Essentially, FDA officials say they are concerned that homeopathic treatments are being marketed for serious disease and conditions, but products may not have shown clinical benefits. Some products labeled as homeopathic contain potentially harmful ingredients or do not meet current good manufacturing practices, and there have been adverse events and death as a result, the FDA says.

Several yards ago, the FDA warned against the use of homeopathic teething devices containing belladonna, a toxic substance associated with serious adverse events, including seizures and deaths in infants and children.

“In recent years, we’ve seen a large uptick in products labeled as homeopathic that are being marketed for a wide array of diseases an conditions, from the common cold to cancer,” said FDA Commissioner Scott Gottlieb, MD. “In many cases, people may be placing their trust and money in therapies that may bring little to no benefit in combating serious ailments or worse.”

Homeopathy officials have spoken out against the FDA plans, with many saying the government should bring together an expert advisory council to examine the issue.

“Homeopathy is beneficial, safe and cost-effective,” wrote Ronald W. Dushkin, MD, the President of the American Institute of Homeopathy, in a comment about the FDA plans. “Integrating it more broadly into the U.S. healthcare system will contribute generously toward the resolution of many pressing social and public health crises affecting our society.”

“If the FDA’s intent is to fully reevaluate its approach to the regulation of homeopathic drugs, then a rush to declare all of them illegal (i.e., unapproved new drugs) is immensely counterproductive,” he added.

Other homeopathy officials, including Paola Brown, President of the Americans for Homeopathy Choice, submitted a petition to the FDA saying that the agency should establish an expert advisory committee on homeopathy. — Joe Cantlupe. (This was part of a piece I wrote for

HCPnow

To Achieve Success, Hospitals Know It’s Not Only About Patient Care -It’s About Data Capture, Meeting Billing Demands, Improving Patient Registration….

See  my story at athenahealth_Insight

With 455 beds and nearly 23,000 patient admissions each year, South Nassau Communities Hospital in Oceanside, New York, practices day-to-day healthcare in a big way.

Officials at the hospital, one of the largest in Nassau County on Long Island and the flagship of the Mount Sinai Health System, know that success at that scale isn’t just about taking care of patients.

It’s about capturing data as the hospital welcomes new practices to its fold. And it’s about meeting billing demands, improving patient registration, and efficiently manning the front desk.

To meet those goals, the hospital relies on its clinicians and staff, and on a secret weapon: Management Services Organizations (MSOs).

South Nassau contracts with at least two MSOs at any given time for an array of hospital needs, including billing and help in onboarding new physician practices, says Elizabeth Durante, administrative director of physician integration.

“We use MSOs in a lot of ways. We have another layer of support by utilizing an MSO,” says Durante.

 

— Joe Cantlupe

 

Your Doc Wants to Give You the Care. You Want the Care. Insurers are Iffy…..the Prior Authorization Nightmare

A huge headache for the healthcare industry is “prior authorization” – the bureaucratic nightmare of getting approvals from insurers for what doctors say is needed care.

CAQH,  a non-profit Washington, DC-based alliance of health plans and trade associations, released a report last month –  detailed by Health Data Buzz  – that shows how these prior authorizations  have hamstrung the move toward using electronic records, with a resultant significant loss of clinician time and spiraling monetary costs.

That is merely the latest in a string of concerns about payer prior authorization requirements, which increases doctor practice burdens and overwhelms patients, according to multiple organizations.

Major  healthcare associations say there has been a big push the past two years to change the prior authorization system, though progress comes slowly. At this point, there are many pleas for reform and  organizations insist they are  banding together to try to make changes happen.

A HeavyWeight Outcry

Earlier this year, the American Medical Association,  Medical Group Management Association  and other groups issued  an urgent consensus statement that outlined what they termed a shared commitment to establish industry-wide improvements  to reduce the onerous prior authorization process in which approvals are needed by health plans, benefit managers, and others. Last week,  CAQH added their major concerns.

The groups  expressing dismay include other powerhouses, insurers among them:  the American Hospital Association, America’s Health Insurance Plans, American Pharmacists Association, Blue Cross Blue Shield Association, among others.

In March, an American Medical Association  survey showed that more than nine in 10 physicians reported that prior authorization programs “have a negative impact on patient clinical outcomes.”

The problems, MGMA says,  are wrapped around agreements between health plans and participating physicians in which “the insurer has the right to determine the medical necessity of surgery, imaging studies, medication and many other procedures.”

Physicians have to divert their attention from clinical and  administrative staff time – as well as resources – to work on submitting preauthorization requests for services, MGMA says.

“Health plan demands for prior approval for physician-ordered medical tests, clinical procedures, medications and medical devices ceaselessly question the judgment of physicians, resulting in less time to treat patients and needlessly drive up administrative costs for medical groups,” said MGMA’s President and CEO Halee Fischer-Wright, MD, in a statement.

Impact on Patients

According to referralmd, while many preauthorization approvals are used for  expensive drugs, generally “66% of prescriptions that get rejected at the pharmacy require prior authorization.”  It adds:  “Not only is this negative for pharmaceutical organizations, most importantly this causes frustration to patients who don’t get the medication that could best treat their condition, or who don’t get any therapy at all.”

“Strict or bureaucratic oversight programs for drug or medical treatments have delayed access to necessary care, wasted limited healthcare resources and antagonized patients and physicians alike,” AMA President Andrew W. Gurman, MD, said in a statement. “The AMA joins the other coalition organizations in urging health insurers and others to apply the reform principles and streamline requirements, lengthy assessments and inconsistent rules in current prior-authorization programs.”

The groups wanting change have outlined a set of 21  principles aimed at helping patients receive what they term timely and medically necessary care and medications and reduce the administrative burden.

Making Things Better

Among other things, they have several suggestions for improvement.

For instance, they said there can be a regular review of medical services and prescription drugs that are subject to prior authorization requirements that would more easily  identify those which may not be necessary because of “low variation in utilization or low prior authorization denial rates.”

In addition, they added:  “effective communication channels between health plans, health care providers and patients are necessary to ensure timely resolution of prior authorization requests to minimize care delays and clearly articulate prior authorization requirements, criteria, rational and program changes”

“Clearly, industry action on prior authorization is needed,” wrote CAQH in a letter last week. “Substantially improving prior authorizations on behalf of the industry ranks among our highest priorities in 2018.”

Impact on Electronic Record and Efficiencies

According to its 2017  CAQH Index adoption of the standard prior authorization transaction by health plans and providers could result in savings of $6.84 per transaction, one of the most significant per transaction opportunity areas, it said.

But the “proportion of prior authorization transactions using that standard actually declined by more than 10 percentage points” from the previous year’s Index report. According to the CAQH Index, providers conduct 77 million prior authorization transactions manually each year. It said: “Providers could save more than $3.20 per transaction and health plans could save at least $3.64 per transaction with fully electronic prior authorizations.”

The goal of the coalition is to shed a “bright light on today’s prior authorization requirements and offer tangible recommendations for improving the current process.”

Let’s see how far, with its list of principles, and the glare of the spotlight, these organizations can go to change a process that is harming many.

— Joe Cantlupe, HealthDataBuzz.