1 00:00:00,160 --> 00:00:02,319 Hi, everyone. This is Lucas Voss with Becker's 2 00:00:02,319 --> 00:00:04,480 Healthcare. Thanks so much for tuning in to 3 00:00:04,480 --> 00:00:07,519 the Becker's Healthcare podcast series. Fantastic to have 4 00:00:07,519 --> 00:00:10,740 you. An exciting topic today, strategies for progress 5 00:00:11,119 --> 00:00:14,580 around e prior authorization in a complex landscape. 6 00:00:14,994 --> 00:00:15,734 And I'm 7 00:00:16,274 --> 00:00:18,535 very excited to be joined by Steven Berko, 8 00:00:18,594 --> 00:00:21,954 senior advisor, value based care inner systems, and 9 00:00:21,954 --> 00:00:24,914 Robert Tennant, executive director at the work group 10 00:00:24,914 --> 00:00:28,054 for electronic data interchange or WEDI. 11 00:00:28,420 --> 00:00:29,859 Steven and Robert, thanks so much for being 12 00:00:29,859 --> 00:00:31,239 here today. It's great to have you. 13 00:00:31,780 --> 00:00:34,740 Thanks for having us. Appreciate it. I wanna 14 00:00:34,740 --> 00:00:37,460 start off with introductions for our audience here. 15 00:00:37,780 --> 00:00:39,299 Steven, why don't you kick us off? Could 16 00:00:39,299 --> 00:00:40,420 you just give us a little bit of 17 00:00:40,420 --> 00:00:42,100 background on yourself and and your work in 18 00:00:42,100 --> 00:00:44,524 health care? Yeah. Sure. Happy to. I've been 19 00:00:44,524 --> 00:00:46,924 kicking around health care for almost thirty years. 20 00:00:46,924 --> 00:00:47,405 I, 21 00:00:47,804 --> 00:00:49,325 have been in the start off as an 22 00:00:49,325 --> 00:00:52,125 executive on the provider side and then through 23 00:00:52,125 --> 00:00:55,645 acquisition, actually switched over to the, health plan 24 00:00:55,645 --> 00:00:56,145 side. 25 00:00:56,660 --> 00:00:58,740 And along the way, I just have become 26 00:00:58,740 --> 00:00:59,960 increasingly convinced 27 00:01:00,500 --> 00:01:00,820 if, 28 00:01:01,300 --> 00:01:04,659 we're truly gonna advance the, quadruple aim or 29 00:01:04,659 --> 00:01:06,439 value based care in health care, 30 00:01:06,740 --> 00:01:08,980 we have got to figure out how to 31 00:01:08,980 --> 00:01:11,240 fully harness the power of data. 32 00:01:11,775 --> 00:01:14,094 So about a year ago, I moved over 33 00:01:14,094 --> 00:01:15,555 to intersystems thinking, 34 00:01:16,174 --> 00:01:18,194 what's a better place to try to advance 35 00:01:18,255 --> 00:01:19,474 that kind of calling 36 00:01:20,094 --> 00:01:22,355 than to be inside kind of a worldwide 37 00:01:22,415 --> 00:01:23,795 leader in health care interoperability 38 00:01:24,255 --> 00:01:25,395 with special expertise 39 00:01:26,609 --> 00:01:29,569 in, integrating clinical data. So that's how a 40 00:01:29,569 --> 00:01:30,069 GM 41 00:01:30,450 --> 00:01:31,270 who's not 42 00:01:31,730 --> 00:01:33,670 a coder wound up at InterSystems. 43 00:01:34,530 --> 00:01:35,890 Well, it's great to have you. Thanks for 44 00:01:35,890 --> 00:01:37,810 being here. Robert, we'll kick it over to 45 00:01:37,810 --> 00:01:38,310 you. 46 00:01:38,865 --> 00:01:39,365 Yeah. 47 00:01:40,224 --> 00:01:41,025 Pleasure to join, 48 00:01:41,665 --> 00:01:43,284 Steve and on this podcast. 49 00:01:43,905 --> 00:01:45,905 I've been in health care for almost as 50 00:01:45,905 --> 00:01:46,224 long. 51 00:01:46,704 --> 00:01:48,944 I spent almost twenty five years at the 52 00:01:48,944 --> 00:01:51,204 Medical Group Management Association 53 00:01:52,010 --> 00:01:53,689 as the director of, 54 00:01:54,090 --> 00:01:55,630 health information technology 55 00:01:56,090 --> 00:01:56,590 policy. 56 00:01:57,530 --> 00:01:58,250 And then I, 57 00:01:58,810 --> 00:02:00,590 transitioned over to WEDI 58 00:02:01,049 --> 00:02:02,750 about five years ago 59 00:02:03,049 --> 00:02:07,069 and then, became executive director earlier this year. 60 00:02:07,875 --> 00:02:10,594 For those that aren't familiar with WEDI, we 61 00:02:10,594 --> 00:02:12,935 were named in HIPAA as an adviser 62 00:02:13,235 --> 00:02:13,974 to HHS, 63 00:02:14,514 --> 00:02:15,655 and we represent, 64 00:02:16,115 --> 00:02:17,655 really the the broad 65 00:02:17,955 --> 00:02:20,754 spectrum of health care. Everybody from the health 66 00:02:20,754 --> 00:02:22,830 plan side to the provider side, 67 00:02:23,229 --> 00:02:23,729 associations, 68 00:02:24,590 --> 00:02:26,210 vendors, clearing houses, 69 00:02:26,590 --> 00:02:29,650 standards development organizations, and, actually, 70 00:02:30,110 --> 00:02:31,330 federal and state 71 00:02:31,710 --> 00:02:34,930 government. Both, CMS and ASTP ONC 72 00:02:35,310 --> 00:02:37,490 serve on the WEDI board of directors. 73 00:02:38,465 --> 00:02:40,245 It's so great to have you both on. 74 00:02:40,465 --> 00:02:43,025 Both great perspectives for this topic, I think. 75 00:02:43,025 --> 00:02:44,865 And I wanna start off with just sort 76 00:02:44,865 --> 00:02:45,925 of level setting, 77 00:02:46,305 --> 00:02:48,145 the situation that we're in and what we're 78 00:02:48,145 --> 00:02:49,205 talking about today. 79 00:02:49,584 --> 00:02:50,194 There is a lot of talk about the 80 00:02:50,194 --> 00:02:50,292 regulatory mandate around e prior authorization, a lot 81 00:02:50,292 --> 00:02:51,800 of conversation. It's regulatory 82 00:02:53,219 --> 00:02:55,020 mandate around e prior authorization, a lot of 83 00:02:55,020 --> 00:02:57,319 conversation. It's widely seen as a step forward 84 00:02:57,540 --> 00:02:58,120 by most, 85 00:02:58,500 --> 00:03:00,740 but there's also limits, important limits that come 86 00:03:00,740 --> 00:03:02,340 with it. I'd love to get both of 87 00:03:02,340 --> 00:03:05,139 your perspectives on this. What should health system 88 00:03:05,139 --> 00:03:08,485 leaders understand about the mandate, what the mandate 89 00:03:08,485 --> 00:03:11,444 does, and really doesn't address? Steven, why don't 90 00:03:11,444 --> 00:03:12,344 we start with you? 91 00:03:13,365 --> 00:03:14,805 I I think one of the things that's 92 00:03:15,044 --> 00:03:16,564 you know, that always brings Rob and I 93 00:03:16,564 --> 00:03:17,625 together in conversations 94 00:03:17,925 --> 00:03:19,784 is we both work with 95 00:03:20,669 --> 00:03:21,569 cross constituency. 96 00:03:22,430 --> 00:03:24,349 So we both work with health plans. We 97 00:03:24,349 --> 00:03:26,109 both I'm a vendor, so he works with 98 00:03:26,109 --> 00:03:26,609 me, 99 00:03:26,989 --> 00:03:29,389 but we both work with providers. We work 100 00:03:29,389 --> 00:03:30,209 with HIEs. 101 00:03:30,590 --> 00:03:31,729 We work with QHIMs. 102 00:03:32,269 --> 00:03:33,650 We're supporting them. 103 00:03:34,064 --> 00:03:37,025 Rob's team is representing them, trying to, 104 00:03:37,824 --> 00:03:39,264 and I and I think, like, the big 105 00:03:39,264 --> 00:03:40,705 thing that I think when you start to 106 00:03:40,705 --> 00:03:42,245 think about all those constituencies, 107 00:03:42,544 --> 00:03:44,884 so outside of the government at this point, 108 00:03:45,264 --> 00:03:46,724 is balls in your court. 109 00:03:47,129 --> 00:03:49,930 And the, I think sometimes people construe what's 110 00:03:49,930 --> 00:03:51,849 in o o five seven with regard to 111 00:03:51,849 --> 00:03:52,349 EPA 112 00:03:52,889 --> 00:03:54,430 as, you know, a lockstep 113 00:03:54,810 --> 00:03:57,550 map for how we're gonna get to electronic 114 00:03:57,689 --> 00:03:58,509 prior authorization. 115 00:03:59,064 --> 00:04:01,084 And what the government has really done 116 00:04:01,384 --> 00:04:03,884 is just given us enough of the blueprint 117 00:04:04,664 --> 00:04:07,405 to get going, to try to say, let's 118 00:04:07,625 --> 00:04:10,764 pull health care into the modern data exchange 119 00:04:10,985 --> 00:04:11,884 via APIs. 120 00:04:13,030 --> 00:04:14,870 But in terms of how that's gonna build 121 00:04:14,870 --> 00:04:16,709 out to the plan back end, how that's 122 00:04:16,709 --> 00:04:18,870 gonna reach out to the providers, there's a 123 00:04:18,870 --> 00:04:21,110 lot that's been left to the private sector 124 00:04:21,110 --> 00:04:22,250 to figure out. 125 00:04:22,709 --> 00:04:24,870 And so if we wanna get compliance to 126 00:04:24,870 --> 00:04:25,930 actual value, 127 00:04:26,574 --> 00:04:28,095 I I actually think it's good news. You 128 00:04:28,095 --> 00:04:29,615 know, sometimes people are like, wait a minute. 129 00:04:29,615 --> 00:04:32,014 But the government hasn't exactly specified how to 130 00:04:32,014 --> 00:04:34,175 do this. But on the other hand, when 131 00:04:34,175 --> 00:04:36,175 you really talk with people, don't you wanna 132 00:04:36,175 --> 00:04:38,335 be able to fill that in yourself knowing 133 00:04:38,335 --> 00:04:40,175 that you're the people who are gonna actually 134 00:04:40,175 --> 00:04:41,634 have to perform against it? 135 00:04:42,180 --> 00:04:44,600 Robert, I'm sure, you echo some of this 136 00:04:44,660 --> 00:04:47,300 similar perspective. I'd love to get your thoughts 137 00:04:47,300 --> 00:04:47,960 as well. 138 00:04:48,740 --> 00:04:51,460 Yeah. Yeah. I'll I'll I'll tackle the question 139 00:04:51,460 --> 00:04:53,080 from the policy side. 140 00:04:53,620 --> 00:04:55,699 It's a it's been a long time coming. 141 00:04:55,699 --> 00:04:56,920 I think we've seen 142 00:04:57,435 --> 00:05:00,335 survey results coming out from provider associations 143 00:05:00,795 --> 00:05:01,935 indicating that 144 00:05:02,314 --> 00:05:05,615 this issue prior authorization is the leading administrative 145 00:05:05,835 --> 00:05:06,335 burden, 146 00:05:06,875 --> 00:05:09,134 that they believe is facing 147 00:05:09,514 --> 00:05:10,735 Madison today. 148 00:05:11,115 --> 00:05:13,939 I think this rule that came out in 149 00:05:13,939 --> 00:05:16,199 early January twenty twenty four 150 00:05:16,580 --> 00:05:17,480 was the culmination 151 00:05:17,780 --> 00:05:20,259 of a lot of issues. I think, we 152 00:05:20,259 --> 00:05:23,379 saw some movement on Capitol Hill there. There 153 00:05:23,379 --> 00:05:24,199 was a bipartisan, 154 00:05:24,580 --> 00:05:25,080 bicameral, 155 00:05:26,180 --> 00:05:30,014 effort to pass legislation, which would essentially do 156 00:05:30,014 --> 00:05:31,314 what this regulation 157 00:05:31,694 --> 00:05:32,194 does, 158 00:05:33,134 --> 00:05:35,935 also include transparency. It's a big part of 159 00:05:35,935 --> 00:05:38,574 of the final rule is the requirement for 160 00:05:38,574 --> 00:05:40,319 health plans to let, 161 00:05:40,879 --> 00:05:43,060 you know, patients and, policymakers 162 00:05:43,600 --> 00:05:46,720 know what the landscape looks like for prior 163 00:05:46,720 --> 00:05:49,360 authorization. How many are approved? How many are 164 00:05:49,360 --> 00:05:52,020 denied? So I think there was some public 165 00:05:52,160 --> 00:05:52,660 pressure 166 00:05:53,120 --> 00:05:56,944 put on the industry to tackle this particular 167 00:05:57,084 --> 00:05:59,964 issue. And we saw, of course, the first 168 00:05:59,964 --> 00:06:02,495 iteration of the rule came out in December 169 00:06:02,495 --> 00:06:03,344 2020 170 00:06:03,485 --> 00:06:05,264 under the first Trump administration. 171 00:06:05,805 --> 00:06:06,944 The Biden administration 172 00:06:07,245 --> 00:06:08,305 actually expanded 173 00:06:08,740 --> 00:06:10,919 that to include Medicare Advantage, 174 00:06:11,220 --> 00:06:13,319 and so that's where we sit now. 175 00:06:13,779 --> 00:06:16,500 But I think, as Stephen said, it's really 176 00:06:16,500 --> 00:06:17,399 a transformation 177 00:06:18,339 --> 00:06:19,159 of the way 178 00:06:19,620 --> 00:06:20,439 prior authorization 179 00:06:20,740 --> 00:06:23,459 data is exchanged, and I think that's the 180 00:06:23,459 --> 00:06:24,495 exciting part. 181 00:06:25,454 --> 00:06:27,954 I think, again, it's happened because, 182 00:06:28,735 --> 00:06:29,475 the current, 183 00:06:30,254 --> 00:06:31,794 electronic data interchange 184 00:06:32,415 --> 00:06:35,314 standard known as the x twelve two seventy 185 00:06:35,375 --> 00:06:36,274 eight transaction 186 00:06:36,894 --> 00:06:39,954 really didn't get much traction in the industry. 187 00:06:40,389 --> 00:06:40,889 So 188 00:06:41,189 --> 00:06:41,689 providers, 189 00:06:42,149 --> 00:06:44,949 and payers were relying on fax machines, on 190 00:06:44,949 --> 00:06:46,729 on portals, on phone calls, 191 00:06:47,029 --> 00:06:50,389 and it's simply not sustainable. So I think 192 00:06:50,389 --> 00:06:53,930 the rule begins to move the industry forward. 193 00:06:54,884 --> 00:06:56,964 And speaking of that, Robert, just staying with 194 00:06:56,964 --> 00:06:58,245 that, just as a follow-up to that, you 195 00:06:58,245 --> 00:06:59,845 mentioned moving forward and you've also talked about 196 00:06:59,845 --> 00:07:01,685 the landscape and, obviously, the changing piece of 197 00:07:01,685 --> 00:07:02,185 this. 198 00:07:02,564 --> 00:07:05,125 How how are you seeing this change, especially 199 00:07:05,125 --> 00:07:07,524 when we look at the start of 2027? 200 00:07:07,524 --> 00:07:09,899 How how are you anticipating the EPA landscape 201 00:07:09,899 --> 00:07:10,479 to change? 202 00:07:11,339 --> 00:07:12,220 Yeah. I think, 203 00:07:12,779 --> 00:07:15,419 what we're seeing is sort of a a 204 00:07:15,419 --> 00:07:15,919 coalescing 205 00:07:16,300 --> 00:07:19,419 around the the rule. It's not a rule 206 00:07:19,419 --> 00:07:21,740 that we're seeing a lot of pushback on. 207 00:07:21,740 --> 00:07:23,084 I think in particular, 208 00:07:23,865 --> 00:07:26,745 because commercial plans were not covered under the 209 00:07:26,745 --> 00:07:29,865 rule, there was some concern that the commercial 210 00:07:29,865 --> 00:07:32,044 lines of business would not support 211 00:07:32,345 --> 00:07:35,944 this new FHIR based API approach to to, 212 00:07:36,105 --> 00:07:37,490 e prior authorization. 213 00:07:37,870 --> 00:07:39,949 That does not appear to be the case. 214 00:07:39,949 --> 00:07:42,670 It looks like the the payer industry is 215 00:07:42,670 --> 00:07:45,009 moving forward in in lockstep. 216 00:07:45,470 --> 00:07:47,089 Obviously, there's gonna be, 217 00:07:47,710 --> 00:07:48,210 variations 218 00:07:48,670 --> 00:07:51,074 on how each health health plan 219 00:07:51,534 --> 00:07:54,254 interprets the rule and implements it. But I 220 00:07:54,254 --> 00:07:55,474 think the consensus 221 00:07:55,774 --> 00:07:59,534 is that this is long overdue, and it's 222 00:07:59,534 --> 00:08:00,435 a a wonderful 223 00:08:00,814 --> 00:08:03,214 step forward for the industry. So I would 224 00:08:03,214 --> 00:08:04,354 say very hopeful 225 00:08:04,819 --> 00:08:08,360 that, the industry will, see some success early 226 00:08:08,500 --> 00:08:09,560 in '27. 227 00:08:09,699 --> 00:08:11,699 Yeah. Lucas, I I think it's very important 228 00:08:11,699 --> 00:08:13,319 that everybody on the line understand 229 00:08:13,939 --> 00:08:15,860 why the start of 2027 230 00:08:15,860 --> 00:08:17,939 is so important. So there's a couple of 231 00:08:17,939 --> 00:08:19,480 effective dates in the regulation, 232 00:08:20,214 --> 00:08:22,794 but the big one is 01/01/1927 233 00:08:23,175 --> 00:08:25,354 when, you know, you have to be compliant 234 00:08:25,414 --> 00:08:27,334 with the regulation. So it's it's a great 235 00:08:27,334 --> 00:08:27,834 question. 236 00:08:28,535 --> 00:08:30,454 And I think what people are starting to 237 00:08:30,454 --> 00:08:32,534 realize is it's not gonna be like a 238 00:08:32,534 --> 00:08:35,539 light switch is gonna get flipped. And increasingly, 239 00:08:35,600 --> 00:08:38,480 there's discussions that if we really want to 240 00:08:38,480 --> 00:08:39,860 kind of transform, 241 00:08:40,240 --> 00:08:42,799 we can't we can't forget the principles of 242 00:08:42,799 --> 00:08:43,700 change management. 243 00:08:44,160 --> 00:08:46,240 And that the way the rule is written, 244 00:08:46,240 --> 00:08:49,200 it doesn't mandate that all providers must move 245 00:08:49,200 --> 00:08:49,940 to EPA. 246 00:08:50,375 --> 00:08:52,794 In effect, it provides this blueprint. 247 00:08:53,254 --> 00:08:56,154 It's a better way. It's using modern APIs 248 00:08:56,214 --> 00:08:58,695 that everybody wants to migrate to. But I 249 00:08:58,695 --> 00:09:01,355 think that the, industry is beginning to recognize 250 00:09:01,495 --> 00:09:03,355 that it's really, really important 251 00:09:03,809 --> 00:09:06,610 that once these solutions go live, they have 252 00:09:06,610 --> 00:09:07,269 to work 253 00:09:07,970 --> 00:09:10,529 because providers are still gonna have the option 254 00:09:10,529 --> 00:09:11,750 for phone and fax. 255 00:09:12,289 --> 00:09:14,450 So it's very, very important. I mean, we 256 00:09:14,450 --> 00:09:16,049 spent a lot of time working with our 257 00:09:16,049 --> 00:09:17,029 clients on 258 00:09:17,615 --> 00:09:20,495 on mapping and testing because what we know 259 00:09:20,495 --> 00:09:22,834 from our conversations with provider leaders, 260 00:09:23,615 --> 00:09:24,894 you know, you're gonna get one or two 261 00:09:24,894 --> 00:09:25,954 bites of the apple, 262 00:09:26,254 --> 00:09:28,355 and then people are going to begin to 263 00:09:28,414 --> 00:09:31,214 kind of decide, hey. Is this better for 264 00:09:31,214 --> 00:09:33,750 me or worse for me? And if they 265 00:09:33,750 --> 00:09:36,389 don't have a good experience upfront, it's gonna 266 00:09:36,389 --> 00:09:38,950 be very, very difficult to overcome that. So 267 00:09:38,950 --> 00:09:40,970 we really encourage people to think about, 268 00:09:41,350 --> 00:09:41,850 hey. 269 00:09:42,629 --> 00:09:45,190 Do what you say well. Don't try to 270 00:09:45,190 --> 00:09:47,110 do everything upfront if you don't have to. 271 00:09:47,110 --> 00:09:49,415 Figure out what those providers really want 272 00:09:49,875 --> 00:09:52,615 to embrace this and be sure that works. 273 00:09:53,475 --> 00:09:55,154 Which also brings me to my next point, 274 00:09:55,154 --> 00:09:57,415 right, is you've talked about the the conversations 275 00:09:57,475 --> 00:09:59,875 that you're having with folks. You both are 276 00:09:59,875 --> 00:10:02,375 are very actively connecting people 277 00:10:02,889 --> 00:10:04,250 in the industry to be able to have 278 00:10:04,250 --> 00:10:07,049 these these conversations. You you bring them together. 279 00:10:07,049 --> 00:10:09,209 You connect them to to talk about it, 280 00:10:09,209 --> 00:10:12,329 to to bring exercises together, to be able 281 00:10:12,329 --> 00:10:14,589 to practice this together, to see what happens. 282 00:10:14,970 --> 00:10:17,735 I'd love to know in these conversations, in 283 00:10:17,735 --> 00:10:20,774 these get togethers, in these exercises, right, that 284 00:10:20,774 --> 00:10:23,574 that you're doing with providers, plants, vendors, etcetera, 285 00:10:23,574 --> 00:10:24,634 all of these elements, 286 00:10:25,014 --> 00:10:27,334 what are the barriers that you're talking about? 287 00:10:27,334 --> 00:10:28,855 You've mentioned some of them in in our 288 00:10:28,855 --> 00:10:30,480 previous answer here, but what are some of 289 00:10:30,480 --> 00:10:32,419 the answers that come up most consistently 290 00:10:32,799 --> 00:10:35,600 as obstacles to that nationwide adoption that we 291 00:10:35,600 --> 00:10:37,279 talked about? Robert, why don't we start with 292 00:10:37,279 --> 00:10:37,779 you? 293 00:10:38,559 --> 00:10:40,080 Well, I'll start by saying, 294 00:10:40,639 --> 00:10:43,304 first of all, it's the nature of prior 295 00:10:43,304 --> 00:10:43,804 authorization. 296 00:10:44,105 --> 00:10:45,725 It is not a binary 297 00:10:46,424 --> 00:10:47,565 simple transaction. 298 00:10:48,184 --> 00:10:49,404 We call it a conversation 299 00:10:50,665 --> 00:10:53,144 rather than a a transaction. So there's a 300 00:10:53,144 --> 00:10:55,625 lot of moving parts, a lot of back 301 00:10:55,625 --> 00:10:58,024 and forth, much more so than, let's say, 302 00:10:58,024 --> 00:11:01,019 a claim. And so the health plans have 303 00:11:01,019 --> 00:11:01,519 developed, 304 00:11:02,139 --> 00:11:03,120 over the years, 305 00:11:03,500 --> 00:11:05,279 medical necessity policies 306 00:11:06,059 --> 00:11:06,559 that 307 00:11:07,100 --> 00:11:10,460 are aren't naturally conducive to moving into an 308 00:11:10,460 --> 00:11:11,600 API environment. 309 00:11:12,059 --> 00:11:13,679 So right from the start, 310 00:11:13,995 --> 00:11:16,794 trying to make sure that they're able to, 311 00:11:16,794 --> 00:11:17,934 in real time, 312 00:11:18,315 --> 00:11:20,715 give an answer to the provider when they 313 00:11:20,715 --> 00:11:22,975 ask, does this service require 314 00:11:23,434 --> 00:11:24,414 a prior authorization? 315 00:11:24,715 --> 00:11:25,695 Yes or no. 316 00:11:26,120 --> 00:11:29,799 That itself is a complicated question because there 317 00:11:29,799 --> 00:11:32,919 are elements of well, it depends. If you 318 00:11:32,919 --> 00:11:35,500 perform this service in the past, then no. 319 00:11:35,879 --> 00:11:38,554 There's also the issue of gold karting. So 320 00:11:38,554 --> 00:11:41,034 all of these data streams have to flow 321 00:11:41,034 --> 00:11:43,615 together. I think as as payers 322 00:11:43,995 --> 00:11:46,495 and their vendor partners are looking at this, 323 00:11:46,554 --> 00:11:49,214 they're trying to solve these these problems. 324 00:11:49,674 --> 00:11:50,174 But, 325 00:11:50,794 --> 00:11:53,490 I think Steven alluded to the fact that 326 00:11:53,730 --> 00:11:56,610 providers are not required. They're not named in 327 00:11:56,610 --> 00:11:58,470 the law to meet this 328 00:11:58,850 --> 00:12:01,409 compliance date. They do have a bit of 329 00:12:01,409 --> 00:12:03,350 a carrot and stick with the 330 00:12:03,809 --> 00:12:04,870 EHR incentive 331 00:12:05,865 --> 00:12:08,504 program so they could lose out on some 332 00:12:08,504 --> 00:12:09,004 incentive 333 00:12:09,384 --> 00:12:12,365 monies. But how do you convince a provider 334 00:12:12,825 --> 00:12:15,065 to adopt the technology? It's not gonna be 335 00:12:15,065 --> 00:12:15,565 cheap, 336 00:12:16,024 --> 00:12:18,585 especially if not all of their health plans 337 00:12:18,585 --> 00:12:20,585 are going to be supporting it. So I 338 00:12:20,585 --> 00:12:22,389 think it's a bit of a chicken and 339 00:12:22,389 --> 00:12:26,090 egg, but I'm hopeful that once the commercial 340 00:12:26,149 --> 00:12:29,029 plans step up and begin to offer this 341 00:12:29,029 --> 00:12:31,850 as an option and the providers realize 342 00:12:32,310 --> 00:12:33,529 that this presents 343 00:12:34,054 --> 00:12:36,695 a solution to what they consider to be 344 00:12:36,695 --> 00:12:37,754 the most burdensome 345 00:12:38,294 --> 00:12:41,735 administrative issue, I'm confident that that will be 346 00:12:41,735 --> 00:12:43,575 able to go forward. So can I get 347 00:12:43,575 --> 00:12:45,355 really weedy about this pun intended? 348 00:12:46,389 --> 00:12:47,370 You may. Yes. 349 00:12:47,750 --> 00:12:48,250 Excellent. 350 00:12:48,710 --> 00:12:50,950 Yeah. We really have been doing root causes. 351 00:12:50,950 --> 00:12:53,669 So I think what people need to know 352 00:12:53,669 --> 00:12:54,409 is that 353 00:12:54,789 --> 00:12:57,190 there have been a number of very limited 354 00:12:57,190 --> 00:12:57,690 pilots 355 00:12:58,230 --> 00:13:00,570 that have really proved the concept. 356 00:13:01,254 --> 00:13:02,634 On a limited basis, 357 00:13:03,254 --> 00:13:04,934 you know, we have been able to show 358 00:13:04,934 --> 00:13:08,054 that you can dramatically actually reduce the number 359 00:13:08,054 --> 00:13:09,034 of prior authorization 360 00:13:09,414 --> 00:13:12,534 requests that are required. You can dramatically reduce 361 00:13:12,534 --> 00:13:15,274 the amount of human time needed to process 362 00:13:15,334 --> 00:13:15,834 things. 363 00:13:16,309 --> 00:13:18,470 There's been a strong proof of concept that 364 00:13:18,470 --> 00:13:20,789 there's a win win win here, but those 365 00:13:20,789 --> 00:13:22,809 have been for very limited, 366 00:13:23,350 --> 00:13:25,909 you know, datasets and groups and whatnot. And 367 00:13:25,909 --> 00:13:26,809 what we're seeing 368 00:13:27,190 --> 00:13:30,044 is the industry is struggling to scale. Right? 369 00:13:30,044 --> 00:13:32,044 We wanna transform. We wanna do this for 370 00:13:32,044 --> 00:13:34,204 everyone, and it's very hard to get there 371 00:13:34,204 --> 00:13:36,524 by making point to point connections. And what 372 00:13:36,524 --> 00:13:39,084 I mean that is each plan having to 373 00:13:39,084 --> 00:13:42,524 connect individually with each provider organization and vice 374 00:13:42,524 --> 00:13:43,024 versa. 375 00:13:43,799 --> 00:13:45,419 So I started doing these, 376 00:13:45,799 --> 00:13:46,779 root cause sessions 377 00:13:47,159 --> 00:13:50,600 with different constituencies to understand what's blocking, what's 378 00:13:50,600 --> 00:13:53,240 it gonna take to scale, and Weedy actually, 379 00:13:53,480 --> 00:13:55,559 helped me with that recently. A couple months 380 00:13:55,559 --> 00:13:56,460 ago in Chicago, 381 00:13:56,919 --> 00:13:58,860 we got we brought together a 100 382 00:13:59,475 --> 00:14:01,735 leaders, most in person, a few virtually. 383 00:14:02,195 --> 00:14:03,014 And, quantitatively, 384 00:14:03,394 --> 00:14:05,235 there was actually a real answer. There were 385 00:14:05,235 --> 00:14:06,774 really two things that popped 386 00:14:07,075 --> 00:14:08,914 in terms of, at least right now, what 387 00:14:08,914 --> 00:14:10,294 are the primary barriers. 388 00:14:10,754 --> 00:14:13,554 Number one, it's this this age old thing 389 00:14:13,554 --> 00:14:16,750 that we still have too many siloed systems 390 00:14:16,889 --> 00:14:18,909 that speak different different formats 391 00:14:19,449 --> 00:14:22,730 in EPA. So even though the government has 392 00:14:22,730 --> 00:14:23,230 established 393 00:14:23,610 --> 00:14:25,610 that we're gonna have APIs in the center 394 00:14:25,610 --> 00:14:26,350 of the communication, 395 00:14:26,825 --> 00:14:28,585 On both sides, we're gonna have to get 396 00:14:28,585 --> 00:14:31,485 things into a common FHIR format to facilitate 397 00:14:31,544 --> 00:14:33,964 that exchange. And then the other thing 398 00:14:34,664 --> 00:14:35,404 is actually 399 00:14:35,705 --> 00:14:36,524 not technical. 400 00:14:37,225 --> 00:14:39,565 It's just the aversion to change. 401 00:14:40,139 --> 00:14:41,980 And what we have to recognize, and it 402 00:14:41,980 --> 00:14:44,220 goes back to a little bit about if 403 00:14:44,220 --> 00:14:46,299 we're gonna transform, it's not all about the 404 00:14:46,299 --> 00:14:46,799 technology. 405 00:14:47,660 --> 00:14:48,799 Maybe said poorly, 406 00:14:49,179 --> 00:14:50,620 there are a lot of people out in 407 00:14:50,620 --> 00:14:53,144 health care who are very, very good at 408 00:14:53,144 --> 00:14:56,205 making this very inefficient EPA system work. 409 00:14:56,665 --> 00:14:58,264 So we're gonna have to ask people to 410 00:14:58,264 --> 00:15:00,105 make a lot of changes in terms of 411 00:15:00,105 --> 00:15:02,105 how they do their workflows. There's people who 412 00:15:02,105 --> 00:15:04,045 understand how to get prior authorizations 413 00:15:04,425 --> 00:15:06,285 approved via phone and fax. 414 00:15:07,059 --> 00:15:08,980 So, I mean, that's the other thing. I 415 00:15:08,980 --> 00:15:10,279 think we have to recognize 416 00:15:10,899 --> 00:15:13,220 that as we're trying to leap forward to 417 00:15:13,220 --> 00:15:15,159 this new way of doing prior authorization, 418 00:15:16,019 --> 00:15:17,860 we gotta figure out a way to bring 419 00:15:17,860 --> 00:15:20,404 along all these people who are very good 420 00:15:20,404 --> 00:15:22,485 at making what I call a broken system 421 00:15:22,485 --> 00:15:24,404 work. So with all of these people and 422 00:15:24,404 --> 00:15:26,004 you mentioned the win win win. Right? And 423 00:15:26,004 --> 00:15:27,764 you've also talked about all of these different 424 00:15:27,764 --> 00:15:29,705 elements that are involved in this process. 425 00:15:30,245 --> 00:15:31,845 Is there a right way forward? Is there 426 00:15:31,845 --> 00:15:32,345 consensus? 427 00:15:32,964 --> 00:15:35,279 Or is it completely different depending on who 428 00:15:35,279 --> 00:15:37,600 you're talking to? Well, I mean, at a 429 00:15:37,600 --> 00:15:38,819 100,000 feet, 430 00:15:39,120 --> 00:15:41,679 absolutely. And there's some very good news. There's 431 00:15:41,679 --> 00:15:41,919 a, 432 00:15:42,559 --> 00:15:43,299 a multi, 433 00:15:44,000 --> 00:15:47,084 segment group. It's called the DaVinci Group, and 434 00:15:47,084 --> 00:15:49,745 they have put out these things called IGs. 435 00:15:49,804 --> 00:15:51,644 And there's three of them called the burden 436 00:15:51,644 --> 00:15:52,865 reduction IGs 437 00:15:53,245 --> 00:15:56,144 that are actually highly recommended in the regulation 438 00:15:56,764 --> 00:15:59,725 as the right path to leap forward to 439 00:15:59,725 --> 00:16:01,745 this new way of doing prior authorization. 440 00:16:02,740 --> 00:16:04,279 And the good news is 441 00:16:04,660 --> 00:16:06,759 you gotta look pretty far now, 442 00:16:07,700 --> 00:16:09,700 to find somebody who doesn't think at a 443 00:16:09,700 --> 00:16:10,580 100,000 444 00:16:10,580 --> 00:16:13,860 feet, the right way forward is actually to 445 00:16:13,860 --> 00:16:16,679 achieve electronic prior authorization, EPA, 446 00:16:17,445 --> 00:16:18,425 by implementing 447 00:16:18,805 --> 00:16:21,144 these three burden reduction IGs. 448 00:16:22,245 --> 00:16:26,245 So 100,000 feet, conceptually, yeah, I think most 449 00:16:26,245 --> 00:16:28,485 people are on board. The challenge, of course, 450 00:16:28,485 --> 00:16:30,690 is when you come down to 10,000 feet. 451 00:16:30,929 --> 00:16:33,029 And I think what people have to recognize 452 00:16:33,090 --> 00:16:35,490 is, yeah, I said win win win, but, 453 00:16:35,490 --> 00:16:36,629 you know, historically, 454 00:16:37,490 --> 00:16:39,730 prior authorization has been a huge point of 455 00:16:39,730 --> 00:16:40,230 tension 456 00:16:40,610 --> 00:16:42,470 between providers and payers. 457 00:16:43,585 --> 00:16:44,085 And, 458 00:16:44,625 --> 00:16:47,504 we are struggling, shall I say, maybe to 459 00:16:47,504 --> 00:16:49,504 build trust. We all wanna get to the 460 00:16:49,504 --> 00:16:51,904 future. We, you know, we kinda know what 461 00:16:51,904 --> 00:16:53,284 that future looks like, 462 00:16:53,904 --> 00:16:55,745 but, you know, there's, like you know, some 463 00:16:55,745 --> 00:16:57,389 of the sessions that we need. There's been 464 00:16:57,389 --> 00:17:00,190 some really healthy dialogue between payers and plan 465 00:17:00,350 --> 00:17:01,330 plans and providers 466 00:17:02,029 --> 00:17:04,829 about a lot of the upfront investment to 467 00:17:04,829 --> 00:17:05,730 really get there 468 00:17:06,109 --> 00:17:08,430 lands on the plans, and the plans are 469 00:17:08,430 --> 00:17:09,329 kinda saying, 470 00:17:09,835 --> 00:17:13,115 I'm willing to make that investment if I'm 471 00:17:13,115 --> 00:17:14,414 confident that providers, 472 00:17:15,035 --> 00:17:16,815 you're gonna use this channel 473 00:17:17,355 --> 00:17:20,075 for electronic prior authorization. It goes back to 474 00:17:20,075 --> 00:17:23,319 where Rob started us, the the EDI four 475 00:17:23,319 --> 00:17:25,880 runners, the two seventy eights, and, you know, 476 00:17:25,880 --> 00:17:28,359 there's the ways that was done before, it 477 00:17:28,359 --> 00:17:29,339 wasn't utilized. 478 00:17:30,279 --> 00:17:32,919 So it's a little bit of a chicken 479 00:17:32,919 --> 00:17:35,019 and egg problem that we have to overcome, 480 00:17:35,845 --> 00:17:37,924 and I don't think we've quite figured out 481 00:17:37,924 --> 00:17:39,205 how to turn the dial on that. I 482 00:17:39,205 --> 00:17:40,664 don't know, Rob. How do you see it? 483 00:17:41,445 --> 00:17:43,365 Yeah. You know, there's a few, what I 484 00:17:43,365 --> 00:17:43,865 call, 485 00:17:44,245 --> 00:17:47,144 drivers that have happened over the last, frankly, 486 00:17:47,205 --> 00:17:48,345 the last few months. 487 00:17:48,679 --> 00:17:51,740 One is the June 23 announce announcement 488 00:17:52,279 --> 00:17:53,339 made by HHS 489 00:17:53,960 --> 00:17:57,000 where they gathered about 50 of the leading 490 00:17:57,000 --> 00:17:58,380 health plans in the nation 491 00:17:58,839 --> 00:18:00,679 to sign a pledge to say they were 492 00:18:00,679 --> 00:18:01,579 going to support 493 00:18:01,934 --> 00:18:04,274 these fire APIs for prior authorization. 494 00:18:04,734 --> 00:18:06,434 That was a tremendous 495 00:18:07,534 --> 00:18:09,454 shot in the arm, I think, for the 496 00:18:09,454 --> 00:18:09,954 industry. 497 00:18:10,335 --> 00:18:11,075 The second 498 00:18:11,454 --> 00:18:13,855 was and and Steven alluded to it, the 499 00:18:13,855 --> 00:18:14,914 fact that providers, 500 00:18:15,294 --> 00:18:17,054 you know, they may be on the fence 501 00:18:17,054 --> 00:18:19,099 because if they don't have the 502 00:18:19,400 --> 00:18:21,019 support with their software 503 00:18:21,480 --> 00:18:23,160 vendors, they're not gonna be able to take 504 00:18:23,160 --> 00:18:26,140 advantage of this. That in part was solved 505 00:18:26,279 --> 00:18:27,180 with the release, 506 00:18:27,720 --> 00:18:31,660 by, ASTP ONC of the HTI four rule, 507 00:18:31,960 --> 00:18:33,035 which requires 508 00:18:33,335 --> 00:18:34,955 APIs to be embedded 509 00:18:35,414 --> 00:18:35,914 into 510 00:18:36,215 --> 00:18:37,674 the EHR certification 511 00:18:38,375 --> 00:18:38,875 program 512 00:18:39,414 --> 00:18:39,914 and 513 00:18:40,455 --> 00:18:41,674 adherence to, 514 00:18:42,775 --> 00:18:44,875 one version of the implementation 515 00:18:45,174 --> 00:18:45,674 guide. 516 00:18:46,055 --> 00:18:48,880 So a big, big change there. The other 517 00:18:48,880 --> 00:18:49,380 piece, 518 00:18:49,840 --> 00:18:51,700 which is more on the horizon, 519 00:18:52,400 --> 00:18:53,539 is this week, 520 00:18:54,320 --> 00:18:57,059 the what's called the unified agenda was 521 00:18:57,440 --> 00:18:59,220 published, which is the regulatory 522 00:18:59,759 --> 00:19:01,940 blueprint for the federal government. 523 00:19:02,375 --> 00:19:04,394 Included in that was, 524 00:19:04,775 --> 00:19:07,835 a proposed rule that to include drugs 525 00:19:08,375 --> 00:19:09,994 in the zero zero five 526 00:19:11,095 --> 00:19:13,914 seven rule because drugs were excluded 527 00:19:14,549 --> 00:19:15,769 in the final rule, 528 00:19:16,150 --> 00:19:18,650 and providers, you know, lament that 529 00:19:18,950 --> 00:19:20,410 many of the prior authorizations 530 00:19:20,950 --> 00:19:22,009 revolve around, 531 00:19:22,390 --> 00:19:25,590 around drugs. So to include that, perhaps not 532 00:19:25,590 --> 00:19:28,090 right away, but down the road, again, 533 00:19:28,470 --> 00:19:28,970 fuels 534 00:19:29,394 --> 00:19:32,054 fuels the fire and will hopefully encourage 535 00:19:32,434 --> 00:19:32,934 providers, 536 00:19:33,315 --> 00:19:34,775 to invest in the technology. 537 00:19:35,394 --> 00:19:37,474 Well, we'll certainly have to schedule a follow-up 538 00:19:37,474 --> 00:19:39,394 podcast to discuss all of those again, I 539 00:19:39,394 --> 00:19:40,134 feel like. 540 00:19:40,755 --> 00:19:42,994 Well, Robert and and Steven, thanks so much 541 00:19:42,994 --> 00:19:44,890 for being here. This is fantastic. I I 542 00:19:44,890 --> 00:19:46,650 wanna turn the floor over to you for 543 00:19:46,650 --> 00:19:48,809 for some closing remarks here. Anything else that 544 00:19:48,809 --> 00:19:50,490 we haven't touched on that that you'd like 545 00:19:50,490 --> 00:19:52,329 to share, before we close? Steven, why don't 546 00:19:52,329 --> 00:19:54,170 we start with you? Yeah. I got I 547 00:19:54,170 --> 00:19:55,130 got two thoughts. 548 00:19:55,930 --> 00:19:57,549 I I think one of the things 549 00:19:58,204 --> 00:20:00,464 that you talked about a path forward, and 550 00:20:01,484 --> 00:20:02,545 I actually think 551 00:20:02,924 --> 00:20:04,625 kind of the fact that 552 00:20:05,404 --> 00:20:08,045 the regulation doesn't try to stip doesn't try 553 00:20:08,045 --> 00:20:10,619 to cross every t and dot every I. 554 00:20:10,940 --> 00:20:13,099 So we've got this nice setup now where 555 00:20:13,099 --> 00:20:15,099 we have a regulation that says there's certain 556 00:20:15,099 --> 00:20:17,259 things that must be in place by one 557 00:20:17,259 --> 00:20:18,480 one '27. 558 00:20:18,619 --> 00:20:20,940 We highly recommend that the right way to 559 00:20:20,940 --> 00:20:21,599 do this 560 00:20:22,140 --> 00:20:24,634 is through these DaVinci burden reduction 561 00:20:24,934 --> 00:20:27,654 IGs. That's the longer term road map, but 562 00:20:27,654 --> 00:20:30,215 there's tremendous wiggle room in terms of how 563 00:20:30,215 --> 00:20:32,455 do you get from what has to be 564 00:20:32,455 --> 00:20:34,775 in place on one one twenty seven to 565 00:20:34,775 --> 00:20:37,680 doing everything we wanna do via the burden 566 00:20:37,680 --> 00:20:40,080 reduction IGs. And I think one of the 567 00:20:40,080 --> 00:20:41,920 things that we're spending a lot of times 568 00:20:41,920 --> 00:20:44,400 working with clients on is not letting the 569 00:20:44,400 --> 00:20:46,400 perfect be the enemy of the good. We're 570 00:20:46,400 --> 00:20:48,480 talking a lot with their providers in terms 571 00:20:48,480 --> 00:20:50,144 of what are your workflows. What do you 572 00:20:50,144 --> 00:20:51,365 actually need upfront 573 00:20:51,825 --> 00:20:54,225 to wanna start walking this path? And what 574 00:20:54,225 --> 00:20:56,085 is it what is okay 575 00:20:56,625 --> 00:20:58,785 if we start to suss that in over 576 00:20:58,785 --> 00:21:00,865 time? So I think that's something I really 577 00:21:00,865 --> 00:21:03,285 encourage everybody to do. If you're a plan, 578 00:21:03,380 --> 00:21:05,380 talk with your provider network. If you're a 579 00:21:05,380 --> 00:21:07,940 providers, talk with your plans. Can we try 580 00:21:07,940 --> 00:21:10,420 to collectively not let the perfect be the 581 00:21:10,420 --> 00:21:12,580 enemy of the good? As Rob likes to 582 00:21:12,580 --> 00:21:14,840 say, we need a glide path to perfection, 583 00:21:15,220 --> 00:21:16,580 and I think it makes it a lot 584 00:21:16,580 --> 00:21:19,000 more doable. And the last thing I'll say 585 00:21:19,275 --> 00:21:19,775 is, 586 00:21:20,234 --> 00:21:20,894 my gosh, 587 00:21:22,315 --> 00:21:22,474 if, 588 00:21:23,275 --> 00:21:25,515 if before my career is over, if I 589 00:21:25,515 --> 00:21:27,295 can just be a small part 590 00:21:27,674 --> 00:21:28,654 of transforming 591 00:21:29,115 --> 00:21:29,615 EPA, 592 00:21:29,914 --> 00:21:32,015 so it excuse me, prior authorization, 593 00:21:32,795 --> 00:21:33,934 so it is 594 00:21:34,799 --> 00:21:35,299 seamless. 595 00:21:36,639 --> 00:21:38,720 I'll feel like, I I I had a 596 00:21:38,720 --> 00:21:40,799 small part in something really big, and I 597 00:21:40,799 --> 00:21:43,119 hope everybody feels that way. I'm hopeful we'll 598 00:21:43,119 --> 00:21:45,599 get there. Robert, go ahead. Any last thoughts 599 00:21:45,599 --> 00:21:46,515 there? Yeah. 600 00:21:46,994 --> 00:21:48,035 Yeah. Agree with everything, 601 00:21:48,515 --> 00:21:51,634 Steven said. I'll add two things. One, the 602 00:21:51,634 --> 00:21:53,734 old adage, it takes a village. 603 00:21:54,355 --> 00:21:56,515 The only way for the industry to move 604 00:21:56,515 --> 00:21:58,914 forward is to do it together. We have 605 00:21:58,914 --> 00:21:59,974 to share 606 00:22:00,509 --> 00:22:03,230 the pain and share the the the success. 607 00:22:03,230 --> 00:22:06,750 We we have to educate ourselves on how 608 00:22:06,750 --> 00:22:09,330 to do this. There this is brand new 609 00:22:09,710 --> 00:22:12,670 technology for health care, and so I think 610 00:22:12,670 --> 00:22:13,730 we need to work 611 00:22:14,125 --> 00:22:14,625 together. 612 00:22:15,005 --> 00:22:16,224 The second is, 613 00:22:17,164 --> 00:22:19,585 I love the idea of 614 00:22:19,884 --> 00:22:21,964 of the glide path and the glide path 615 00:22:21,964 --> 00:22:23,265 being even beyond 616 00:22:23,644 --> 00:22:24,944 prior authorization. 617 00:22:25,325 --> 00:22:27,049 I think this echoes, 618 00:22:27,589 --> 00:22:29,289 the the or has the potential 619 00:22:29,669 --> 00:22:30,730 of being a revolution 620 00:22:31,190 --> 00:22:31,929 in how, 621 00:22:32,230 --> 00:22:33,929 payers and providers exchange 622 00:22:34,630 --> 00:22:36,250 data in all ways. 623 00:22:37,349 --> 00:22:40,095 The the third quick point is, you know, 624 00:22:40,234 --> 00:22:41,855 the other, of approaches, 625 00:22:42,474 --> 00:22:45,115 are probably not going away, but what what 626 00:22:45,115 --> 00:22:47,134 we need to do is prove the value, 627 00:22:47,595 --> 00:22:50,875 and and that will drive everybody to move, 628 00:22:51,355 --> 00:22:51,855 forward. 629 00:22:52,640 --> 00:22:54,399 Well, Steven and Robert, again, thank you so 630 00:22:54,399 --> 00:22:56,240 much for being here. Such great insights. And, 631 00:22:56,240 --> 00:22:57,919 again, we'll have to do this again. There's 632 00:22:57,919 --> 00:23:00,079 so much, moving so many moving parts that 633 00:23:00,079 --> 00:23:01,519 I feel like in a couple months, we'll 634 00:23:01,519 --> 00:23:02,500 have to meet again 635 00:23:02,880 --> 00:23:05,039 and discuss this again. Again, thank you all 636 00:23:05,039 --> 00:23:06,965 for being here. We also want to thank 637 00:23:06,965 --> 00:23:09,365 our podcast sponsor inner systems. You can tune 638 00:23:09,365 --> 00:23:11,684 into more podcasts from Becker's healthcare by visiting 639 00:23:11,684 --> 00:23:15,545 our podcast page at becker'shospitalreview.com.