One of the sessions at the 5th annual Oncology Clinical Pathways Congress addressed how providers and accountable groups can align their quality and outcomes goals, as well as how the health care landscape is influencing changes in this arena.
Speakers Amy Schroeder, RPh, Senior Consultant Pharmacist, Avalere Health, and Roy Beveridge, MD, Senior Healthcare Advisor, Avalere Health, gave a joint presentation to review the evolution of health plan benefit decision-makers and to discuss ways to reduce the burden of insurer requirements for coverage and payment.
Roughly 10 to 15 years ago, they said, the US health care system was firmly a fee-for-service (FFS) system. Employers were paying for employee insurance benefits; plans were administrative services only (ASO) or self-funded; and the goal was to reduce spend within the offered benefit. Within this past dynamic, insurers were working at the behest of employers to save money, and providers had to request permission to prescribe services. It was pure gain for the employer to reduce FFS costs by authorizing less service activity, and there was no gain for the insurer beyond fees paid by the employer.
As the dynamic has evolved, employers have moved to contracts shifting risk to insurers. Insurers have become more involved in reducing cost while keeping (commercial) benefit the same. Risk discussions occur to align on expectations, ie, providers are asking for more data to meet those expectations. In addition, members stay with a plan for an average of 3 years, so there is more data to share. Insurers are now more interested in rate control than care control—it is more about the value of a service in relation to its cost.
Presenters then compared how key types of insurers operate so has to better understand their role in the system and how control of prior authorizations is also very different. They looked at (1) commercial/fully insured, (2) commercial ASO or self-funded, (3) Medicare FFS, (4) Medicare Advantage, and (5) Managed Medicaid. Regardless, of how the plan operates, the best way to manage how care is actually covered and reimbursed for these different types of plans, said Dr Schroeder, is to really think about providing that health plan with enough information for them to make a decision. They noted that you need to determine the source and reason for the coverage issue to plan how to engage and resolve it. You need to understand the details of the plan, type of contract, and population served to understand how that patient’s plan works. In any insurer transaction, they said, there needs to be transparency of clinical intent in the data submitted. Dr Beveridge expanded upon this, saying that it is crucial to remember that, even with commercial insurance, there are differences in the requirements set for a prior authorization.
They then examined the role of the payer in clinical pathways. Dr Schroeder said that “one of the things they have learned at Avalere in speaking with providers as well as pathway vendors, and also health plans or payers that use them, is that pathways really are a clinical blueprint of what the provider is going to execute.” Because the treatment plan is documented, the prior authorization segment is “just a click,” which can streamline the approval process. Pathways can provide the transparency and clinical intent for the insurer to understand the plan (eg, need for supportive care). Risk-bearing entities are on the same page, Dr Schroeder noted. With pathways, providers are actually documenting what they are doing, and the insurer can then easily understand what that intent is, so everyone is clear on what the plan is and care can move forward.—Amanda Del Signore
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