Streamlining and Reimagining Prior Authorization Under Value-Based Contracts: A Call to Action From the Value in...

Area of Science:

• Health Policy
• Cardiovascular Medicine
• Healthcare Administration

Background:

• Utilization management, including prior authorization, is essential for safe and guideline-adherent cardiovascular therapies.
• Current prior authorization systems create significant administrative burdens and frustrations for patients, clinicians, and payers.
• The shift to value-based payment necessitates a reevaluation of utilization management strategies.

Purpose of the Study:

• To describe the efforts and vision of the Prior Authorization Learning Collaborative for reimagining utilization management.
• To outline how healthcare organizations can assume greater utilization management responsibility under value-based contracting.
• To present options for streamlining prior authorization processes.

Main Methods:

• Review of current utilization management strategies and their impact on stakeholders.
• Analysis of the role of healthcare organizations in value-based contracting for utilization management.
• Exploration of streamlining options like gold carding and electronic/automated prior authorization.

Main Results:

• Reimagining utilization management can create a more transparent and collaborative system.
• Healthcare organizations can take on increased utilization management responsibilities, especially in value-based arrangements.
• Streamlining options can reduce administrative burden and improve efficiency.

Conclusions:

• Collective action is needed to transform prior authorization into a more efficient and patient-centered process.
• Reimagined utilization management can reduce administrative burden for clinicians and payers.
• Improved utilization management strategies can lead to better patient outcomes in cardiovascular care.