Session (CTI)

ISSUE: Prior authorization (PA) requires a care provider to obtain a health plan’s approval for a treatment or service before the plan will provide coverage. PA has become a prevalent component of healthcare benefit design, used to contain costs and manage prescription drug use. However, as PA has expanded, it has become a source of frustration across healthcare stakeholders. Policy reform activity has recently accelerated, but may be missing the mark. Payers acknowledge PA limitations but say it is an essential tool for ensuring clinically appropriate care and maintaining affordability. Patients report delays and disruptions in access, while clinicians experience administrative burden in navigating complex rules and appeals processes. Researchers have analyzed the implementation and impact of PA, including instances where restrictions are inconsistent with clinical guidelines. As PA reform activity intensifies, there is ongoing debate over how it should be scoped and executed. Payers seek to preserve mechanisms that promote appropriate care and contain costs, while patients and clinicians underscore the access barriers and harms created by current practices. Researchers seek to provide evidence to inform the discussions. This session will frame the current debate by examining trends in PA implementation over time and its impact on healthcare delivery and patient care from multiple stakeholder perspectives. It will highlight PA technology opportunities, ongoing reform efforts and aim to identify areas of common ground among stakeholders to support the development of more transparent and standardized approaches. OVERVIEW: Westrich will review the evolution of UM/PA and recent policy reform efforts (10 min) Chambers, Tsiao, and Hyde will share their perspectives on the application of PA in benefit design and patient care and how it can be improved (10 min each; see panelist perspective section for details). Moderated Q&A will explore common ground for meaningful reform and address audience questions (20 mins).