New set of provider coalition prior authorization principles

Patient-centered care has emerged as a major common goal across the health care industry. By empowering patients to play an active role in their care and assume a pivotal role in developing an individualized treatment plan to meet their health care needs, this care model can increase patients’ satisfaction with provided services and ultimately improve treatment quality and outcomes.  

Yet despite these clear advantages to adopting patient-centered care, health care providers and patients often face significant obstacles in putting this concept into practice. Utilization management programs, such as prior authorization and step therapy, can create significant barriers for patients by delaying the start or continuation of necessary treatment and negatively affecting patient health outcomes. The very manual, time-consuming processes used in these programs burden providers (physician practices, pharmacies and hospitals) and divert valuable resources away from direct patient care. However, health plans and benefit managers contend that utilization management programs are employed to control costs and ensure appropriate treatment.

Recognizing the investment that the health insurance industry will continue to place in these programs, a multi-stakeholder group representing patients, physicians, hospitals and pharmacists (see organizations listed in left column) has developed the following principles on utilization management programs to reduce the negative impact they have on patients, providers and the health care system. This group strongly urges health plans, benefit managers and any other party conducting utilization management (“utilization review entities”), as well as accreditation organizations, to apply the following principles to utilization management programs for both medical and pharmacy benefits. We believe adherence to these principles will ensure that patients have timely access to treatment and reduce administrative costs to the health care system.
 

View the principles