Hi, everyone. This is Lucas Voss with Becker's
Healthcare. Thanks so much for tuning in to
the Becker's Healthcare podcast series. Fantastic to have
you. An exciting topic today, strategies for progress
around e prior authorization in a complex landscape.
And I'm
very excited to be joined by Steven Berko,
senior advisor, value based care inner systems, and
Robert Tennant, executive director at the work group
for electronic data interchange or WEDI.
Steven and Robert, thanks so much for being
here today. It's great to have you.
Thanks for having us. Appreciate it. I wanna
start off with introductions for our audience here.
Steven, why don't you kick us off? Could
you just give us a little bit of
background on yourself and and your work in
health care? Yeah. Sure. Happy to. I've been
kicking around health care for almost thirty years.
I,
have been in the start off as an
executive on the provider side and then through
acquisition, actually switched over to the, health plan
side.
And along the way, I just have become
increasingly convinced
if,
we're truly gonna advance the, quadruple aim or
value based care in health care,
we have got to figure out how to
fully harness the power of data.
So about a year ago, I moved over
to intersystems thinking,
what's a better place to try to advance
that kind of calling
than to be inside kind of a worldwide
leader in health care interoperability
with special expertise
in, integrating clinical data. So that's how a
GM
who's not
a coder wound up at InterSystems.
Well, it's great to have you. Thanks for
being here. Robert, we'll kick it over to
you.
Yeah.
Pleasure to join,
Steve and on this podcast.
I've been in health care for almost as
long.
I spent almost twenty five years at the
Medical Group Management Association
as the director of,
health information technology
policy.
And then I,
transitioned over to WEDI
about five years ago
and then, became executive director earlier this year.
For those that aren't familiar with WEDI, we
were named in HIPAA as an adviser
to HHS,
and we represent,
really the the broad
spectrum of health care. Everybody from the health
plan side to the provider side,
associations,
vendors, clearing houses,
standards development organizations, and, actually,
federal and state
government. Both, CMS and ASTP ONC
serve on the WEDI board of directors.
It's so great to have you both on.
Both great perspectives for this topic, I think.
And I wanna start off with just sort
of level setting,
the situation that we're in and what we're
talking about today.
There is a lot of talk about the
regulatory mandate around e prior authorization, a lot
of conversation. It's regulatory
mandate around e prior authorization, a lot of
conversation. It's widely seen as a step forward
by most,
but there's also limits, important limits that come
with it. I'd love to get both of
your perspectives on this. What should health system
leaders understand about the mandate, what the mandate
does, and really doesn't address? Steven, why don't
we start with you?
I I think one of the things that's
you know, that always brings Rob and I
together in conversations
is we both work with
cross constituency.
So we both work with health plans. We
both I'm a vendor, so he works with
me,
but we both work with providers. We work
with HIEs.
We work with QHIMs.
We're supporting them.
Rob's team is representing them, trying to,
and I and I think, like, the big
thing that I think when you start to
think about all those constituencies,
so outside of the government at this point,
is balls in your court.
And the, I think sometimes people construe what's
in o o five seven with regard to
EPA
as, you know, a lockstep
map for how we're gonna get to electronic
prior authorization.
And what the government has really done
is just given us enough of the blueprint
to get going, to try to say, let's
pull health care into the modern data exchange
via APIs.
But in terms of how that's gonna build
out to the plan back end, how that's
gonna reach out to the providers, there's a
lot that's been left to the private sector
to figure out.
And so if we wanna get compliance to
actual value,
I I actually think it's good news. You
know, sometimes people are like, wait a minute.
But the government hasn't exactly specified how to
do this. But on the other hand, when
you really talk with people, don't you wanna
be able to fill that in yourself knowing
that you're the people who are gonna actually
have to perform against it?
Robert, I'm sure, you echo some of this
similar perspective. I'd love to get your thoughts
as well.
Yeah. Yeah. I'll I'll I'll tackle the question
from the policy side.
It's a it's been a long time coming.
I think we've seen
survey results coming out from provider associations
indicating that
this issue prior authorization is the leading administrative
burden,
that they believe is facing
Madison today.
I think this rule that came out in
early January twenty twenty four
was the culmination
of a lot of issues. I think, we
saw some movement on Capitol Hill there. There
was a bipartisan,
bicameral,
effort to pass legislation, which would essentially do
what this regulation
does,
also include transparency. It's a big part of
of the final rule is the requirement for
health plans to let,
you know, patients and, policymakers
know what the landscape looks like for prior
authorization. How many are approved? How many are
denied? So I think there was some public
pressure
put on the industry to tackle this particular
issue. And we saw, of course, the first
iteration of the rule came out in December
2020
under the first Trump administration.
The Biden administration
actually expanded
that to include Medicare Advantage,
and so that's where we sit now.
But I think, as Stephen said, it's really
a transformation
of the way
prior authorization
data is exchanged, and I think that's the
exciting part.
I think, again, it's happened because,
the current,
electronic data interchange
standard known as the x twelve two seventy
eight transaction
really didn't get much traction in the industry.
So
providers,
and payers were relying on fax machines, on
on portals, on phone calls,
and it's simply not sustainable. So I think
the rule begins to move the industry forward.
And speaking of that, Robert, just staying with
that, just as a follow-up to that, you
mentioned moving forward and you've also talked about
the landscape and, obviously, the changing piece of
this.
How how are you seeing this change, especially
when we look at the start of 2027?
How how are you anticipating the EPA landscape
to change?
Yeah. I think,
what we're seeing is sort of a a
coalescing
around the the rule. It's not a rule
that we're seeing a lot of pushback on.
I think in particular,
because commercial plans were not covered under the
rule, there was some concern that the commercial
lines of business would not support
this new FHIR based API approach to to,
e prior authorization.
That does not appear to be the case.
It looks like the the payer industry is
moving forward in in lockstep.
Obviously, there's gonna be,
variations
on how each health health plan
interprets the rule and implements it. But I
think the consensus
is that this is long overdue, and it's
a a wonderful
step forward for the industry. So I would
say very hopeful
that, the industry will, see some success early
in '27.
Yeah. Lucas, I I think it's very important
that everybody on the line understand
why the start of 2027
is so important. So there's a couple of
effective dates in the regulation,
but the big one is 01/01/1927
when, you know, you have to be compliant
with the regulation. So it's it's a great
question.
And I think what people are starting to
realize is it's not gonna be like a
light switch is gonna get flipped. And increasingly,
there's discussions that if we really want to
kind of transform,
we can't we can't forget the principles of
change management.
And that the way the rule is written,
it doesn't mandate that all providers must move
to EPA.
In effect, it provides this blueprint.
It's a better way. It's using modern APIs
that everybody wants to migrate to. But I
think that the, industry is beginning to recognize
that it's really, really important
that once these solutions go live, they have
to work
because providers are still gonna have the option
for phone and fax.
So it's very, very important. I mean, we
spent a lot of time working with our
clients on
on mapping and testing because what we know
from our conversations with provider leaders,
you know, you're gonna get one or two
bites of the apple,
and then people are going to begin to
kind of decide, hey. Is this better for
me or worse for me? And if they
don't have a good experience upfront, it's gonna
be very, very difficult to overcome that. So
we really encourage people to think about,
hey.
Do what you say well. Don't try to
do everything upfront if you don't have to.
Figure out what those providers really want
to embrace this and be sure that works.
Which also brings me to my next point,
right, is you've talked about the the conversations
that you're having with folks. You both are
are very actively connecting people
in the industry to be able to have
these these conversations. You you bring them together.
You connect them to to talk about it,
to to bring exercises together, to be able
to practice this together, to see what happens.
I'd love to know in these conversations, in
these get togethers, in these exercises, right, that
that you're doing with providers, plants, vendors, etcetera,
all of these elements,
what are the barriers that you're talking about?
You've mentioned some of them in in our
previous answer here, but what are some of
the answers that come up most consistently
as obstacles to that nationwide adoption that we
talked about? Robert, why don't we start with
you?
Well, I'll start by saying,
first of all, it's the nature of prior
authorization.
It is not a binary
simple transaction.
We call it a conversation
rather than a a transaction. So there's a
lot of moving parts, a lot of back
and forth, much more so than, let's say,
a claim. And so the health plans have
developed,
over the years,
medical necessity policies
that
are aren't naturally conducive to moving into an
API environment.
So right from the start,
trying to make sure that they're able to,
in real time,
give an answer to the provider when they
ask, does this service require
a prior authorization?
Yes or no.
That itself is a complicated question because there
are elements of well, it depends. If you
perform this service in the past, then no.
There's also the issue of gold karting. So
all of these data streams have to flow
together. I think as as payers
and their vendor partners are looking at this,
they're trying to solve these these problems.
But,
I think Steven alluded to the fact that
providers are not required. They're not named in
the law to meet this
compliance date. They do have a bit of
a carrot and stick with the
EHR incentive
program so they could lose out on some
incentive
monies. But how do you convince a provider
to adopt the technology? It's not gonna be
cheap,
especially if not all of their health plans
are going to be supporting it. So I
think it's a bit of a chicken and
egg, but I'm hopeful that once the commercial
plans step up and begin to offer this
as an option and the providers realize
that this presents
a solution to what they consider to be
the most burdensome
administrative issue, I'm confident that that will be
able to go forward. So can I get
really weedy about this pun intended?
You may. Yes.
Excellent.
Yeah. We really have been doing root causes.
So I think what people need to know
is that
there have been a number of very limited
pilots
that have really proved the concept.
On a limited basis,
you know, we have been able to show
that you can dramatically actually reduce the number
of prior authorization
requests that are required. You can dramatically reduce
the amount of human time needed to process
things.
There's been a strong proof of concept that
there's a win win win here, but those
have been for very limited,
you know, datasets and groups and whatnot. And
what we're seeing
is the industry is struggling to scale. Right?
We wanna transform. We wanna do this for
everyone, and it's very hard to get there
by making point to point connections. And what
I mean that is each plan having to
connect individually with each provider organization and vice
versa.
So I started doing these,
root cause sessions
with different constituencies to understand what's blocking, what's
it gonna take to scale, and Weedy actually,
helped me with that recently. A couple months
ago in Chicago,
we got we brought together a 100
leaders, most in person, a few virtually.
And, quantitatively,
there was actually a real answer. There were
really two things that popped
in terms of, at least right now, what
are the primary barriers.
Number one, it's this this age old thing
that we still have too many siloed systems
that speak different different formats
in EPA. So even though the government has
established
that we're gonna have APIs in the center
of the communication,
On both sides, we're gonna have to get
things into a common FHIR format to facilitate
that exchange. And then the other thing
is actually
not technical.
It's just the aversion to change.
And what we have to recognize, and it
goes back to a little bit about if
we're gonna transform, it's not all about the
technology.
Maybe said poorly,
there are a lot of people out in
health care who are very, very good at
making this very inefficient EPA system work.
So we're gonna have to ask people to
make a lot of changes in terms of
how they do their workflows. There's people who
understand how to get prior authorizations
approved via phone and fax.
So, I mean, that's the other thing. I
think we have to recognize
that as we're trying to leap forward to
this new way of doing prior authorization,
we gotta figure out a way to bring
along all these people who are very good
at making what I call a broken system
work. So with all of these people and
you mentioned the win win win. Right? And
you've also talked about all of these different
elements that are involved in this process.
Is there a right way forward? Is there
consensus?
Or is it completely different depending on who
you're talking to? Well, I mean, at a
100,000 feet,
absolutely. And there's some very good news. There's
a,
a multi,
segment group. It's called the DaVinci Group, and
they have put out these things called IGs.
And there's three of them called the burden
reduction IGs
that are actually highly recommended in the regulation
as the right path to leap forward to
this new way of doing prior authorization.
And the good news is
you gotta look pretty far now,
to find somebody who doesn't think at a
100,000
feet, the right way forward is actually to
achieve electronic prior authorization, EPA,
by implementing
these three burden reduction IGs.
So 100,000 feet, conceptually, yeah, I think most
people are on board. The challenge, of course,
is when you come down to 10,000 feet.
And I think what people have to recognize
is, yeah, I said win win win, but,
you know, historically,
prior authorization has been a huge point of
tension
between providers and payers.
And,
we are struggling, shall I say, maybe to
build trust. We all wanna get to the
future. We, you know, we kinda know what
that future looks like,
but, you know, there's, like you know, some
of the sessions that we need. There's been
some really healthy dialogue between payers and plan
plans and providers
about a lot of the upfront investment to
really get there
lands on the plans, and the plans are
kinda saying,
I'm willing to make that investment if I'm
confident that providers,
you're gonna use this channel
for electronic prior authorization. It goes back to
where Rob started us, the the EDI four
runners, the two seventy eights, and, you know,
there's the ways that was done before, it
wasn't utilized.
So it's a little bit of a chicken
and egg problem that we have to overcome,
and I don't think we've quite figured out
how to turn the dial on that. I
don't know, Rob. How do you see it?
Yeah. You know, there's a few, what I
call,
drivers that have happened over the last, frankly,
the last few months.
One is the June 23 announce announcement
made by HHS
where they gathered about 50 of the leading
health plans in the nation
to sign a pledge to say they were
going to support
these fire APIs for prior authorization.
That was a tremendous
shot in the arm, I think, for the
industry.
The second
was and and Steven alluded to it, the
fact that providers,
you know, they may be on the fence
because if they don't have the
support with their software
vendors, they're not gonna be able to take
advantage of this. That in part was solved
with the release,
by, ASTP ONC of the HTI four rule,
which requires
APIs to be embedded
into
the EHR certification
program
and
adherence to,
one version of the implementation
guide.
So a big, big change there. The other
piece,
which is more on the horizon,
is this week,
the what's called the unified agenda was
published, which is the regulatory
blueprint for the federal government.
Included in that was,
a proposed rule that to include drugs
in the zero zero five
seven rule because drugs were excluded
in the final rule,
and providers, you know, lament that
many of the prior authorizations
revolve around,
around drugs. So to include that, perhaps not
right away, but down the road, again,
fuels
fuels the fire and will hopefully encourage
providers,
to invest in the technology.
Well, we'll certainly have to schedule a follow-up
podcast to discuss all of those again, I
feel like.
Well, Robert and and Steven, thanks so much
for being here. This is fantastic. I I
wanna turn the floor over to you for
for some closing remarks here. Anything else that
we haven't touched on that that you'd like
to share, before we close? Steven, why don't
we start with you? Yeah. I got I
got two thoughts.
I I think one of the things
that you talked about a path forward, and
I actually think
kind of the fact that
the regulation doesn't try to stip doesn't try
to cross every t and dot every I.
So we've got this nice setup now where
we have a regulation that says there's certain
things that must be in place by one
one '27.
We highly recommend that the right way to
do this
is through these DaVinci burden reduction
IGs. That's the longer term road map, but
there's tremendous wiggle room in terms of how
do you get from what has to be
in place on one one twenty seven to
doing everything we wanna do via the burden
reduction IGs. And I think one of the
things that we're spending a lot of times
working with clients on is not letting the
perfect be the enemy of the good. We're
talking a lot with their providers in terms
of what are your workflows. What do you
actually need upfront
to wanna start walking this path? And what
is it what is okay
if we start to suss that in over
time? So I think that's something I really
encourage everybody to do. If you're a plan,
talk with your provider network. If you're a
providers, talk with your plans. Can we try
to collectively not let the perfect be the
enemy of the good? As Rob likes to
say, we need a glide path to perfection,
and I think it makes it a lot
more doable. And the last thing I'll say
is,
my gosh,
if,
if before my career is over, if I
can just be a small part
of transforming
EPA,
so it excuse me, prior authorization,
so it is
seamless.
I'll feel like, I I I had a
small part in something really big, and I
hope everybody feels that way. I'm hopeful we'll
get there. Robert, go ahead. Any last thoughts
there? Yeah.
Yeah. Agree with everything,
Steven said. I'll add two things. One, the
old adage, it takes a village.
The only way for the industry to move
forward is to do it together. We have
to share
the pain and share the the the success.
We we have to educate ourselves on how
to do this. There this is brand new
technology for health care, and so I think
we need to work
together.
The second is,
I love the idea of
of the glide path and the glide path
being even beyond
prior authorization.
I think this echoes,
the the or has the potential
of being a revolution
in how,
payers and providers exchange
data in all ways.
The the third quick point is, you know,
the other, of approaches,
are probably not going away, but what what
we need to do is prove the value,
and and that will drive everybody to move,
forward.
Well, Steven and Robert, again, thank you so
much for being here. Such great insights. And,
again, we'll have to do this again. There's
so much, moving so many moving parts that
I feel like in a couple months, we'll
have to meet again
and discuss this again. Again, thank you all
for being here. We also want to thank
our podcast sponsor inner systems. You can tune
into more podcasts from Becker's healthcare by visiting
our podcast page at becker'shospitalreview.com.