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Patient Perspective

How Pathways Can Support Reimbursement for Personalized Decision Making and Care Planning

Authored by

Alan Balch, PhD—Column Editor

Affiliation

Patient Advocate Foundation and National Patient Advocate Foundation, Washington, DC

Disclosures

Dr Balch is the chief executive officer at the Patient Advocate Foundation and National Patient Advocate Foundation.

Citation

J Clin Pathways. 2019;5(2):20-22. doi:10.25270/jcp.2019.03.00065

The ideal way to manage the utilization of health care resources in an era of value-based and precision medicine is to require and provide reimbursement for personalized decision making and care planning with evidence-based treatment options while incorporating cost information as a key factor in those decisions. It is time to repurpose in a thoughtful and targeted way many of the resources that currently go into the prior authorization process from the physicians’ offices and insurance companies. Achieving this will require a willingness to break with the past and fully embrace a multistakeholder approach to engineering person-centered shared decision making and care planning processes.


Clinical pathways can potentially be key decision support tools for the effective delivery of personalized medicine by helping to both eliminate unnecessary variation in care and to maximize appropriate variation. Fulfilling this promise of providing the right care to the right patient at the right time requires that pathways be engineered to help match patient characteristics, goals, and preferences with evidence-based treatment options.1 In short, the delivery of personalized medicine will require the use of personalized or precision pathways. 

While the ability for pathways to incorporate more variables that are both clinically, financially, and socially relevant is necessary in an era of person-centered care, pathways are ultimately meant to be a tool to support decision making, not to make the decision.2 A robust shared decision-making process used in conjunction with a personalized pathway protocol will help empower patients to make treatment choices that are both within evidence-based guidelines and reflect their preferences related to a range of key benefits, risks, and costs. The shared decision-making process must then inform a personalized care planning process that includes the selection of one or more patient-reported outcome measures that reflect what matters to patients in terms of quality of life and treatment goals.

The implementation and execution of all these steps to attain true person-centered care will require meaningful collaboration between multiple stakeholders. Collaborators must define the parameters of their approach and implement it in the context of the specific care setting and disease. These stakeholders include: (1) medical professionals who bring the scientific and clinical knowledge and experience to making evidence-based decisions; (2) patients and caregivers who are experts about their own bodies, lives, values, and preferences; and (3) payers/insurance companies who bring expertise in managing cost and measuring the quality of care. The ideal way to manage the utilization of health care resources in an era of value-based and precision medicine is to require and provide reimbursement for personalized decision making and care planning with evidence-based treatment options while incorporating cost information as a key factor in those decisions.

A New Platform for Care

The goal is to develop and implement a system that provides a reliable platform for routine reimbursement of shared decision making and care planning combined with quality measures that are meaningful to patients. Such a system would allow clinicians to personalize care decisions for their patients by providing the time needed to get to know, not only the medical and biological aspects of a patient’s disease, but also their goals and preferences related to their treatment—and reimbursing them for that time.

For patients, this new system would help ensure that they are able to discuss their concerns and goals with their clinicians, increasing the critical areas of trust, respect, and the perception that clinicians are listening to them. This communication is key to personalizing care and going beyond clinical benefits to include quality of life and financial burdens. When a patient and clinician take the time to share what is important and work together to weigh the benefits, risks, and costs of their evidence-based treatment options, insurers should provide “prior authorization” for coverage of the treatment decisions arrived at through that process.

Rethinking Pathways and Utilization Management

The precedent is already being set within clinical pathways for equating utilization management with compliance to a mutually agreed upon process or standard. Some pathways built on clinical guidelines are being integrated into prior authorization protocols, such that an “on pathway” regimen is automatically approved.2,3 This approach has some benefits for clinicians and payers but also augments the current problems with clinical pathways as they relate to the patient perspective. Clinical pathways often do not integrate unique patient attributes adequately into their models. In this new view outlined herein, prior authorization becomes the practice of using shared decision making supported by clinical pathways in combination with personalized care planning and quality measurement to maximize the likelihood of getting the right treatment at the right time for the right patient.

Currently, utilization management generally happens once a patient and clinician have selected an option but prior to the initiation of treatment. This “downstream” approach can put the insurance company in the awkward but sometimes necessary position of debating a provider’s decision without the detailed knowledge the provider has acquired about the patient. 

The current approaches to utilization management create stress for both physicians and patients. A 2017 survey published by the American Medical Association (AMA), based on responses from 1000 practicing physicians, paints a grim picture of the perceived impact of prior authorization on clinical practice4:

  • 84% described the burden of prior authorization on their practice as high or extremely high with respondents saying the process consumes 14.6 hours on average per week
  • 34% report having staff dedicated to this process
  • 54% say that prior authorization often or always delays access to necessary care
  • 61% perceive that the overall impact or prior authorization on patient outcomes is significantly negative

This burden amounts to a very real opportunity cost that consumes time and resources for physicians and detracts from opportunities to improve the patients experience through shared decision making and care planning. 

The intent of utilization management has never been to frustrate physicians or disrupt patient access to needed care. It exists because insurance companies play a critical role in monitoring and managing costs on behalf of their beneficiaries. This responsibility requires careful stewardship to ensure that dollars are spent effectively and efficiently. It could be considered a “trust but verify” model. But it seems evident that this model is not well suited to meet the demands of recent trends for more personalized decision making, patient engagement, consumer-driven health, and value-based payment models.

It is time for a dramatic rethinking and redefining of how insurance companies satisfy their role as fiscal stewards for our health care system. We need new, personalized models of approval and reimbursement that match the medical/scientific shift to personalized care and the market shift to consumer directed care.

some

Some of this collaboration is already underway with the recent release of a consensus statement to improve the prior-authorization process by the AMA, the insurance industry trade group America’s Health Insurance Plans (AHIP), and other stakeholder organizations.5 What is missing is the patient voice.

What If?

What if prior authorization was not a late-stage process that insurance companies administer to gain approval for a treatment after an initial recommendation is made but rather was based on what happens before a decision is made?6

What if, instead, it was a robust, evidence-based decision that uses a uniform, verifiable system of shared decision making, clinical pathways, care planning, and measure selection?

These recommendations may sound lofty, but they are a primary means by which we can fully leverage what we have learned scientifically about the nature of disease in the last decade or so. This progress encompasses a wide range of fields including remarkable new knowledge about the molecular, genetic, and immunologic nature of disease. New understanding has led to new treatments, medications, and tools that have greatly bolstered the evidence base for treating many conditions. But our delivery and reimbursement systems have not undergone a similar reinvention or kept pace with what is happening in science and medicine. In the era of personalized medicine, we remain stuck with tools and systems based on “average patients,” on standardized concepts of population health, and paternalistic, top-down decision health care decision making.

Conclusion

It is time to rethink, to re-engineer our delivery and reimbursement models to bridge this gap. Doing so requires the willingness to break with the past and fully embrace a multistakeholder approach to engineering person-centered shared decision making and care planning processes. At least some of the time and money needed to make this happen are already in the system. It is time to repurpose in a thoughtful and targeted way many of the resources that currently go into the prior authorization process from the physicians’ offices and insurance companies.

We have the potential, today, to take the necessary steps to usher in a new era of consumer-driven health care that allows patients to partner with their providers to make choices about their treatment options based on their knowledge of costs and benefits. 

References

1. Kent J. How to bring precision medicine into routine clinical care. HealthAnalyticsIT.com. July 30, 2018. https://healthitanalytics.com/news/how-to-bring-precision-medicine-into-routine-clinical-care. Accessed February 27, 2019. 

2. Balch AJ, Balch CM, Benson A III, Morosini D, Rifkin RM, Williams LA. Recommendations for the role of clinical pathways in an era of personalized medicine. Am J Manag Care. 2016;22(5, theme issue):SP179-SP180. 

3. American Medical Association. 2017 AMA prior authorization physician survey. https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/public/arc/prior-auth-2017.pdf. Published 2018. Accessed February 27, 2019.   

4. American Journal of Managed Care (AJMC). Kathleen Lokay: clinical pathways can prevent prior authorization [video]. AJMC website. https://www.ajmc.com/conferences/pcoc-2017/kathleen-lokay-clinical-pathways-can-prevent-prior-authorization-delays. Published December 24, 2017. Accessed February 27, 2019.   

5. American Medical Association (AMA). Consensus statement on improving the prior authorization process. https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/public/arc-public/prior-authorization-consensus-statement.pdf. Published 2018. Accessed February 27, 2019.   

6. Change Healthcare. Reinventing utilization management (UM) to bring value to the point of care. HealthcareItNews.com. https://www.healthcareitnews.com/news/reinventing-utilization-management-um-bring-value-point-care. Published September 18, 2017. Accessed February 27, 2019.

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