Page 27 - Delaware Medical Journal - May/June 2018

TRANSFORMATION IN HEALTH CARE
We agree to:
■ Encourage the use of programs that selectively implement prior authorization health care providers’ performance and adherence to evidence-based medicine
■ Encourage (1) the development of criteria to select and maintain health care providers in these selective prior authorization programs with the input of contracted health care providers and/or provider organizations; and (2) making these criteria transparent and easily accessible to contracted providers
■ Encourage appropriate adjustments to prior authorization requirements when health care providers participate in risk- based payment contracts
2. PRIOR AUTHORIZATION PROGRAM REVIEW AND VOLUME ADJUSTMENT. Regular review of the list of medical services and prescription drugs that are subject to prior authorization requirements can help identify therapies that no longer warrant prior authorization
due to, for example, low variation in utilization or low prior authorization denial rates. Regular review can also help identify services, particularly new and emerging therapies, where prior authorization may be warranted due to a lack of evidence on effectiveness or safety concerns.
We agree to:
■ Encourage review of medical services and prescription drugs requiring prior authorization on at least an annual basis, with the input of contracted health care providers and/or provider organizations
■ Encourage revision of prior authorization requirements, including the list of services subject to prior authorization, based on data analytics and up-to-date clinical criteria
■ Encourage the sharing of changes
to the lists of medical services and prescription drugs requiring prior authorization via (1) provider-accessible websites; and (2) at least annual communications to contracted health care providers
3. TRANSPARENCY AND COMMUNICATION REGARDING PRIOR AUTHORIZATION. Effective, two-way 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, rationale, and program changes.
We agree to:
■ Improve communication channels between health plans, health care providers, and patients
■ Encourage transparency and easy accessibility of prior authorization requirements, criteria, rationale, and program changes to contracted health care providers and patients/enrollees
■ Encourage improvement in communication channels to support
(1) timely submission by health care providers of the complete information necessary to make a prior authorization determination as early in the process of prior authorization determinations by health plans to impacted health care providers (both ordering/rendering physicians and dispensing pharmacists) and patients/enrollees
4. CONTINUITY OF PATIENT CARE.
Continuity of patient care is vitally important for patients undergoing an active course of treatment when there is a formulary or treatment coverage
change and/or a change of health plan. Additionally, access to prescription medications for patients on chronic, established therapy can be affected
by prior authorization requirements. Although multiple standards addressing timeliness, continuity of care, and appeals are currently in place, including state and federal law and private accreditation standards, additional efforts to minimize the burdens and patient care disruptions associated with prior authorization should be considered.
We agree to:
■ continuity of care during a transition period for patients undergoing an active course of treatment when there is a formulary or treatment coverage change or change of health plan that may disrupt their current course of treatment
■ Support continuity of care for medical services and prescription medications for patients on appropriate, chronic, stable therapy through minimizing repetitive prior authorization requirements
■ Improve communication between health care providers, health plans, and patients to facilitate continuity of care and minimize disruptions in needed treatment
5. AUTOMATION TO IMPROVE TRANSPARENCY AND EFFICIENCY. Moving toward industry-wide adoption of electronic prior authorization transactions based
on existing national standards has the potential to streamline and improve the process for all stakeholders. Additionally, making prior authorization requirements and other formulary information electronically accessible to health
care providers at the point-of-care in electronic health records (EHRs) and pharmacy systems will improve process
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