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A Call for Prior Authorization and Utilization Management Reform to Improve Patient Centered Cardiovascular Prevention Care.

A central tenet of healthcare quality is patient-centered care. Patient-centered care requires caring for patients and their families in ways that are meaningful and valuable to the individual patient. The Institute of Medicine defined patient-centered care as providing care that is respectful of, and responsive to, individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions. A patientcentered approach can empower patients to play an active role in their care and assume a pivotal role in developing an individualized, evidence-based treatment plan to meet their healthcare needs. Moreover, patients’ satisfaction with care is increased and care quality and outcomes are improved when care is patient centered. The merits of adopting patient-centered care are clear; however, obstacles limit providers’ ability to apply this concept in practice. Recent attention has focused on utilization management programs, such as prior authorization, as a significant barrier to patient-centered, evidence-based care that all too often delays the initiation or continuation of necessary medications, durable medical equipment, and other treatment services and negatively affects patient satisfaction and health outcomes. Prior authorization is any process by which healthcare providers must obtain advance approval from a health plan before a specific service is delivered to the patient to qualify for payment coverage. Health plans use utilization management programs requiring prior authorization as a measure to control costs, ensure provider compliance with evidence-based clinical guidelines, and promote patient safety. Prior authorization remains a primarily manual, time-consuming process that often delays patient access to indicated therapy or even alters the course of therapy and places excessive burden on providers, includingnursesandpharmacists,healthcare practices, and hospitals; disrupts workflow; and diverts valuable resources away from direct patient care. Although estimates vary by type and size of healthcare practice, 1 survey found that, on average, in US practices, physicians spent 3 hours per week interacting with payers, nurses spent 19.1 hours, clerical staff spent 35.9 hours, and lawyers/accountants spent 7.2 hours. This translates into substantial increase in uncompensated overhead healthcare costs. Furthermore, a critical consequence is nonpayment if prior authorization is not obtained in advance of providing the therapy or service. The Center for Medicare and Medicaid Services has broadened prior authorization requirements to an increasing percentage of drugs covered under the Part D Prescription Drug Plan and other service types ‘‘to ensure beneficiary access and reduce improper payments.’’ Concurrently, recent innovations in cardiovascular care include costly new therapies that are necessitating an increase in prior authorization as the Center for Medicare and Medicaid Services and other health plans strive to control costs. Frequently used cardiovascular therapies requiring