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Inside this Issue:

Integrating Clinical and Administrative Data

Our Virtual Advocacy Summit journey continues with a presentation on Integrating Clinical and Administrative Data. This was presented by: Chantal Worzala, Principal, Alazro Consulting, LLC; Laura Hoffman, Assistant Director of Federal Affairs, American Medical Association; Katherine Lusk, Chief Health Information Management and Exchange Officer, Children’s Health System of Texas

This presentation focused on Prior Authorizations (PA) and the challenges healthcare providers face. AMA conducted a Prior Authorization Physician Survey, with 1000 respondents, to determine how PA affect physician practices and their workflow. Of the respondents, the following was reported:
  • 91% experienced care delays
  • 75% lead to treatment abandonment
  • 28% led to serious adverse patient events
  • 31 PAs per physician week with approx. two business days spent complete PA workload
  • 88% report PA burdens have increased
Based on this survey, the AMA, in coalition with 16 organizations, helped to reform these principles and released the Prior Authorization and Utilization Management Reform Principles in January 2017. In January 2018, the Consensus Statement on Improving the Prior Authorization Process was also released. The goal for both is to help promote safe, timely and affordable access to evidence-based care for patients; enhance efficiency; and reduce administrative burdens. The links to the information contained in these releases are below.

With some automation of PAs occurring, there is an urging to policy makers to focus on selective PA applications along with standardization.  An opportunity for this is to review and adjust PA lists and remove low value PA. For example, if you know if some procedures or drugs are approved over 90% of the time, why continue requiring a PA when it would be more beneficial to remove it from the list.  Also, have agreement on standardization across payors.  If one payor requires PA vs. another payor who does not or if payors require different documentation, it would be beneficial to standardize the PA data set by service type which will aid in ease of implementation and privacy/security concerns by ensuring the right documentation is sent.

AMA has been very actively engaged with CMS to move this topic forward to aid in provider burden and ensuring patients are receiving the care or medications they need more timely. 


AMA Prior Authorization & Utilization Management Reform Principles

Consensus Statement on Improving the Prior Authorization Process

AMA Grassroots Website
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