During a House Ways and Means Committee hearing prior to the congressional recess, Rep. Rudy Yakym (R-IN) questioned Vice President of Clinical Quality and Population Health Officer at Avera Health, Dr. David Basel on pre-authorizations.
00:03Thank you, Mr. Chairman, for holding this hearing today and for our witnesses for being here today on such an important topic.
00:09Ensuring our seniors have access to quality health care is an important issue to the Hoosiers and the seniors that I represent.
00:16Medicare Advantage, also known as MA, has been a strong success for America's seniors as we've seen substantial growth in the program over the last two decades.
00:24In 2007, 19 percent of Medicare beneficiaries chose MA plans, and now that's up to 54 percent.
00:33MA enrollees tend to have better outcomes when compared to their peers on traditional Medicare.
00:38Most notably, they have 70 percent fewer hospital readmissions and 25 percent fewer inpatient stays.
00:45But no matter how successful a program is, I think in order to be good stewards of taxpayer dollars,
00:50we must continually look to make programs more effective and more efficient.
00:55I think it's equally important that we keep all stakeholders engaged at the discussion table,
01:01especially seniors and health care providers as we strive for program improvement.
01:05I regularly hear from health care providers in my district that they struggle with the administrative burdens associated with Medicare Advantage,
01:12in particular about prior authorizations,
01:14when a provider must receive authorization from an insurance company before service may be administrated.
01:21I certainly joined my colleagues on both sides of the aisle today with concerns about excessive prior authorizations.
01:27Mr. Basel, can you talk about the impact prior authorizations have on health care providers and the seniors they seek to serve?
01:34So, it's all about where is that sweet spot, because there is a very good case to be made for managing care.
01:41So, you don't want no floodgate to be in there.
01:45So, let's say a patient comes in with abdominal pain, and I don't think there's any concerning symptoms.
01:51I think that they're going to get better in a couple days, but they're really worried and they want a CT.
01:56You know, if there's no care, then the path of least resistance might be, sure, fine.
02:00You can have a CT, but if there's a little bit of prior authorization there, that enables the conversation about, you know,
02:06I just know that the payer is not going to approve this.
02:08Let's wait a couple days, see how things go, maybe start with a plain film.
02:12We actually have a better clinical outcome.
02:14We're not exposing the patient to radiation, and there's actually better care in that situation.
02:19And so, there is a sweet spot there, but it's when that becomes excessive,
02:23and I've got a patient I am worried about that I can't get that necessary CT for what that becomes.
02:28And so, this is not a black and white issue.
02:31This is a where in that spectrum is the sweet spot.
02:35And, Mr. Bosley, you spent several years working with rural health care providers.
02:40Can you share some of the unique challenges prior authorizations pose in these rural communities?
02:45Probably one of the biggest challenges in our rural communities.
02:48You know, in my big tertiary care center, you know, I've got a whole fleet of people that I train up on this,
02:52and they get really good at prior authorizations and denials and peer-to-peers and all of this,
02:58and they become experts in this.
03:00In my rural settings, you know, my director of nursing is also the quality director,
03:04is also the HR director.
03:06Everybody wears multiple hats in these smaller hospitals,
03:08and they can't be an expert in authorizations and denials and stuff, too.
03:13And so, we face an uphill battle.
03:15We try to support them as much centrally as we can,
03:17but it's a whole different ballgame when you can't do this all day, every day,
03:21like some of our larger facilities do.
03:23And what do you see as some of the biggest opportunities to improve the prior authorization process?
03:29Streamline it.
03:30I mean, again, there's tools out there that there's no reason that, you know,
03:3470 percent of these are getting overturned on denial.
03:37They should be able to tell which one of these ahead of time are going to make it through.
03:41And if it's a dotting the I or crossing the T thing,
03:44that should be able to get caught, you know,
03:46through some of the technology tools that we have.
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