Get Real On Pre-authorizations: Interoperability Is Key

There is much left unsaid in the discussion of new Michigan legislation (“Health Can’t Wait”) that would curb insurance pre-approval rules in health care. Pre-authorizations are used not only to keep costs down, but to ensure that unnecessary testing (and physician shopping) is not performed on patients, especially a repeat diagnostic test where the initial test results are available.

Our organization submits at least 1,500 requests for pre-authorizations to payers per quarter, and denials are rare, sometimes zero. That’s because we use the primary care physician to coordinate patient care with specialists, as directed by those who follow the principles of the patient-centered medical home. As much as we need and respect our specialty physicians, they have a reputation of not providing much needed supporting documentation in a timely fashion. Frequently, primary care physicians wait weeks to receive reports on consultations that were completed. Those are often the only items needed to receive the authorization for additional services. I must remind my colleagues that NCQA has specific turn-around times for payers to act on pre-authorization requests. Also, as a primary care physician recently admitted to me, she has some gaps in knowledge on more advanced and often new specialty testing where she appreciates the guidance offered through the pre-authorization process.

Further, while Michigan may look to change the pre-authorization process, it does not have authority to do so for Medicare or Medicaid patients. Such pre-authorizations are required by CMS at the federal level. What this legislation should really be about is interoperability – the growing need for electronic health records to be able to “speak” to each other via a central information repository such as MiHIN, regardless of the software vendor.

I fear I am beginning to tune people out on the dramatic need for interoperability, yet I firmly believe that change will only come through grass roots efforts. If EHRs had been created by the experts who developed secure online banking, I’m convinced we wouldn’t be having this conversation. Yet with the electronic health record industry controlled by a few major players who have nothing to gain by giving up their monopoly – and power – to allow broader access, we must demand change by working in and with smaller groups until collectively we are too large to ignore. (I can’t resist the opportunity to share the popular quote by anthropologist Margaret Mead: “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has.”)

Michigan physician organizations and medical professional societies such as MSMS and MOA can help lead the charge on interoperability, rather than focusing on pre-authorizations. Physicians garner a high level of respect from legislators, influencers and decision makers – and they’ve earned it. When physicians speak, others in authority listen. Yet, without a game plan for achieving interoperability, there will be no meaningful change. We need interoperability because it ensures that doctors, behavioral health specialists, and other healthcare providers have the information they need to provide coordinated care that captures a longitudinal picture of their patients’ health.