Presentation outline by Anupam Goel, MD, Chief Health Information Officer, Clinical Services, United Healthcare presented during eHealth Initiative's Prior Authorization Workshop on October 31, 2018.

How can we move from a blame-oriented system to a learning system?

• We have to move our idea of testing new things beyond “pilotitis*.” As we test new changes, the marketplace also changes. Rather than viewing each test as an intervention without regard to other stakeholder responses (scientists, providers, patients, competitors and regulators), interventions should be considered as a trajectory of problems and solutions (i.e., more “cat & mouse,” less “pushing unilaterally”).
• In a marketplace with low-trust among stakeholders (e.g., members/patients, providers, payers), we should consider using standards that are:
  
  • Robust to different levels of technology or clinical sophistication, and
  • Modular to allow for updates to different process elements without revamping the entire system for all participants.
  • Possible standards include SMART on FHIR and DIRECT for synchronous and asynchronous communication, respectively. CDS Hooks is an emerging standard that might allow different payers to deliver their own content across the same points within the electronic medical record workflow.
• Learning systems benefit from feedback loops
  
  • Feedback to customers (employers, members/patients)
  • Feedback to partners and suppliers

Can evidence-based medicine and patient preferences supplement or replace Prior Authorization?

• Prior Authorization creates the appearance of scarcity and drives irrational behavior among marketplace participants
• Can eliciting patient preferences within the context of evidence-based medicine? At least one entity (Kaiser) thinks so.
• One warning: patient preferences can change over time, challenging static models of the “right care choice.”

What’s the goal of Prior Authorization? Maybe the goal is to change behavior.

• Changing behavior starts with the realization that what I am currently doing is not supporting who I want to be (cognitive dissonance).
• Once I experience cognitive dissonance, do I have the knowledge, skills and attitudes to make a behavioral change?
• K Anders Ericsson (Peak: Secrets from the New Science of Expertise) talks about “deliberate practice,” constantly pushing oneself beyond one’s comfort zone, following training activities designed by an expert to develop special abilities and using feedback to identify weaknesses and work on them. We need to consider this same type of deliberate practice as we consider ways to improve the Prior Authorization process.
  
  • Feedback to orthopedic surgeons from their patients (e.g., KOOS-Jr survey)

Miscellaneous thoughts

• Bundled payments may work best when used in conjunction with Centers of Excellence
  
  • Centers of Excellence identify members who are most likely to benefit from an intervention
  • Bundled payments identify those teams or facilities that perform the intervention at the highest value (quality/cost) once the decision to perform an intervention has occurred
• Care pathways may allow payers, providers and members to forecast short-term future needs (diagnostic, pharmaceutical and medical) as a patient moves through the pathway, facilitating the prior authorization process.
• Advancing Prior Authorization standards will force payers to consider other ways to distinguish themselves in the marketplace. Payer market differentiation opportunities might include facilitating prior authorization from telemedicine or telephone encounters, driving prior authorization through patient functional assessments or patient preferences, identifying providers or medical centers who deliver services tailored to a member/patient’s specific preferences.

*Pilotitis – continued emphasis on demonstrating successful outcomes from narrowly-focused interventions targeting relatively small populations (Huang F et al. “Beyond pilotitis: taking digital health interventions to the national level in China and Uganda.” Globalization and Health, 2017 13:49.