Patient Perspective on Prior Authorization and the Triple Aim Alan Balch, PhD ACC Heart House Roundtable October 11, 2017
OUR MISSION Patient Advocate Foundation is a national 501(c)(3) organization that seeks to safeguard patients ability to access care, maintain employment and preserve their financial stability relative to their diagnosis of chronic, life threatening or debilitating diseases.
Debt Crisis Assistance Financial support: co-pay, discount and indigent drug programs, transportation, housing, food, utility shut off, charity care, negotiate payment plans Screening and Enrollment Assistance Eligibility screening and enrollment: Medicare and Medicaid, SCHIP, SSI and SSDI eligibility screening and enrollment, ACA enrollment support Insurance Navigation Assistance Insurance utilization: benefit review, preauthorization, clinical appeals, hospital billing and coding issues A baseline level of employment related support as needed (e.g., FMLA COBRA, ADA guidance)
Program Scope and Impact
Solving Insurance and Healthcare Access Problems since 1996
52% said pre-approval or prior authorization required for the medication they are currently taking for their primary condition, but only 30% of whom said this request was denied initially. 34% said it took longer than 2 weeks to receive prior authorization approval. In the last 12 months, have you been denied care or treatment because you could not get prior authorization from your insurance company? 13% In the last 12 months, have you had stop your drug treatment and change to another due to your insurance coverage or a change to your coverage? 10%
More than 500 patients to date assisted through this program. Many patients and providers abandon their efforts to get access to novel therapies About 10% of patients die.
When we are able to complete the case work, there is about a 60% success rate for gaining access to treatment. Cases have required an average of 50+ contacts per case to achieve a positive resolution, more than twice the PAF average of 19.89 contacts per case.
Solving Insurance and Healthcare Access Problems since 1996
How do we build a healthcare system that is capable of that level of precision? Does the system decide on behalf of patients when the triple aim has been reached through standards of care? Does the triple aim mean that the standard of care should be personalization? What is the patient s role in helping to determine what is the right care for them at certain points of time?
Eliminate unnecessary variation in care by creating tools and policies that standardize care and/or minimize opportunities for individual characteristics to influence care decisions. Transactional cost = utilization review. Cost containment through efficiency and economies of scale Allowing for appropriate variation in care by creating tools and policies that facilitate opportunities for individual characteristics to influence care decisions. Transactional cost = taking time to personalize the care plan. Cost containment through effectiveness and utility maximization
(n=1,349 low income cancer patients; 90% in treatment in last 12 months; unpublished PAF survey data) How important is it to you that your treatment be highly personalized to the unique characteristics of your cancer? 83% said extremely important How important is it to you that you receive the standard of treatment for most patients diagnosed with the same or similar cancer as yours? 57% said extremely important If you had to choose? 96% said highly personalized treatment
Patients should be empowered to make shared decisions with their physicians that are consistent with their desires (preferences, values). These individual choices must be made in an environment of voluntary cooperation and a coordinated approach to care. Patients generally do not want non-voluntary or forced choice.
Appropriate steps should be taken to encourage and empower providers to engage their patients in a robust decision making process. Physicians must have the freedom to consider a range of viable treatment options and, with the patient, carefully weigh the risks, benefits, and costs associated with them. Avoid policies that might short circuit the decisionmaking process between physicians and patients by substituting or second guessing clinical judgment.
Which of the following best describes your preferred approach for decisions related to medical care? 70% 60% Multiple Myeloma Breast Cancer Other Cancers Hep C HIV 50% 40% 30% 20% 10% 0% I prefer to be completely in charge of my decisions I prefer to make the final decision with input from my doctors and other experts I prefer to make a joint decision with equal input from my doctor I prefer that my doctor makes the decisions with input from me I prefer that my doctor is completely in charge of treatment decision
To what extent do you agree with the following statement: Knowing the cost I am going to pay out of my own pocket for my care is important when it comes to making decisions about what treatments I should take for my disease. 60% 50% Breast Cancer Other Cancers Hep C HIV 40% 30% 20% 10% 0% Strongly disagree Disagree Somewhat disagree Somewhat agree Agree Strongly agree
A relationship with your physician based on respect, interest, compassion, & competence Interactions with the ENTIRE health care team
How difficult or easy was the appeal process for you to navigate and understand? 75% said to slightly to very difficult How satisfied were you with the amount of time it took for your insurance company to provide a response to the prior authorization request? 37% satisfied and 37% dissatisfied How easy or difficult did you find the prior authorization process to understand? 45% slightly to very difficult and 45% slightly to very easy
- All protocols for utilization review should be transparent and based on clinical review criteria. - A standardized form, no longer than two pages, to be used for all prior authorization claims that can be submitted securely and electronically. - Health plan should respond to medically 19 urgent requests within 24 hours, and within 48 to 72 hours for all other medical needs. - Patients should have easily accessible and understandable avenues for appealing utilization review techniques. - A health plan or pharmacy benefit manager should not, without the direct consent of the prescriber, switch patients off of a prescribed medication. 19 National Patient Advocate Foundation 1100 H Street, NW, 7 th Floor Washington, Patient DC Advocate 202-347-8009 Foundation www.npaf.org - Confidential
Currently, 27 states have a law pertaining to prior authorization regulation. Basic reforms we have witnessed 20over the past three years, and which we support are: 1) a universal and user friendly form for PA override requests, 2) electronic submission of override requests, 3) a mandatory time limit for the health plan to respond (or the request is deemed to be approved). 20 National Patient Advocate Foundation 1100 H Street, NW, 7 th Floor Washington, Patient DC Advocate 202-347-8009 Foundation www.npaf.org - Confidential