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Forbes
13 hours ago
- Health
- Forbes
Physician Perspectives On Prior Authorization Reform
Many physicians believe prior authorization gets in the way of sound patient care. New reforms from ... More the insurance industry aim to address these challenges. Will they make a difference? You learn a lot in medical school. About human biology, medical ethics and how to make a diagnosis. One thing they don't teach you about—but which rears its head all the time in the actual practice of medicine—is prior authorization. Prior authorization is what is known in healthcare as a utilization management tool. Physicians submit requests to insurers, who respond with determinations about whether they will cover the proposed procedures, services, or medications before the patient receives them. The goal is to steer customers toward modalities of care that have been demonstrated to produce the best outcomes at a reasonable cost. During office hours, between procedures, even in the middle of consults—prior authorization is something physicians have to deal with constantly. Last week, amid scrutiny from lawmakers and regulators as well as public outrage over the practice, health insurers working with the trade association AHIP (on whose board I sit as CEO of SCAN Health Plan, a not-for-profit health insurance company) announced a set of voluntary commitments aimed at simplifying prior authorization and 'connecting patients more quickly to the care they need while minimizing administrative burdens on providers.' The commitments include faster turnaround times, greater transparency, and reduced requirements for routinely approved services. These reforms are sensible and—let's be honest—probably overdue. But will they make a difference? 'Administrative Hurdles' Despite its daily impact on the practice of medicine, prior authorization isn't something physicians talk about very much. So, in order to gauge how prior authorization affects their work and their patients and what effect the voluntary reforms might have, I reached out to several colleagues in different specialties to hear their stories about prior authorization. What I heard were honest reflections on their experience with the practice—and an urgent call to reimagine a system that too often gets in the way of care. Jay Patel, an orthopedic surgeon in Orange County, CA, specializing in hip and knee replacements, describes a system that increasingly delays care for no clear reason by putting up 'administrative hurdles to surgeries that are appropriate.' Patel notes that some payers require that he submits imaging reports in separate documents that duplicate the information contained in previously submitted medical records. 'Most of the time there's some minor piece of information they need that's already in the record, and they reflexively approve it.' But not always. And when delays occur, he says, they disrupt care and diminish trust between patients and their doctors. 'Patients often don't understand how the process works,' he says. 'They usually think we dropped the ball because we're the person they can get ahold of.' Patel believes the system could be improved by reducing prior authorization requirements for physicians who consistently provide appropriate care. 'Good actors should be able to request surgery and have it approved.''Delays Matter' A Northern California interventional cardiologist I know sees firsthand how delays in care can lead to worse outcomes. 'For every test, you have to wait a week for authorization,' he says. 'And when it comes to cardiac conditions, delays matter.' He laments that the delays can push patients to seek emergency care when they experience shortness of breath or other symptoms. 'Put yourself in their shoes. When your heart hurts you may be afraid you will die.' He says that some of his patients have decided to go to the emergency room rather than wait for approvals. In these cases, the patients are admitted and treated as inpatients, which he notes is ultimately more expensive for the plan, the patient and the health system in general. The cardiologist also notes that in his field, denials are rare. Though he often has to pick up the phone to advocate for a patient, he says that in 11 years of practice, not once has a health plan denied a procedure that he's called about. Knowing this, he wonders if artificial intelligence or other technologies could offer ways to improve the system. 'There must be ways to optimize this. If they're authorizing the procedure 99% of the time, why can't there be instant authorization?' Internist Jonathan Dinh says insurers often use prior authorization as a 'delay tactic.' He says that in his experience, some payers intentionally make the practice burdensome, knowing that some percentage of physicians will become frustrated and give up on the time-consuming prior authorization process. 'If there's a poor clinical outcome, the health plan maintains plausible deniability. They'll say, 'We never said 'no.' We left the decision strictly up to our providers.'' As an internist and medical group leader in Southern California, Dinh believes that the efficiency of prior authorization reflects the quality of the organization itself. 'In a well-run group, 80% to 90% of requests should be auto approved,' he explains. "The primary function of prior authorization should be to ensure patients are referred to the correct in-network provider, helping them avoid unnecessary medical bills—not to act as a barrier to care." Dinh says delegated models in which payors assign certain administrative and clinical responsibilities—like utilization management, care coordination, and prior authorization decisions—to a provider organization or medical group can reduce the friction of prior authorization. However, he cautions that this model alone isn't enough. "Delegated entities can still improperly delay or deny care. There must be safeguards—such as expedited appeal processes—to protect patients.' Dinh also says that patients often mistakenly blame delays in seeing a specialist due to the prior authorization process when the real underlying issue is a shortage of physicians. "People often blame delays in seeing a specialist on the prior authorization process,' he says. 'But in many cases, referrals are issued promptly—the real bottleneck is a shortage of physicians. Specialists are overwhelmed and simply don't have the capacity to see patients quickly. Of course, any delay in prior authorization only makes the situation worse.' To address the broader issue of physician shortages, Dinh and his colleagues launched a new internal medicine residency program focusing on training more primary care internists. The initiative aims to expand access to care and improve outcomes, particularly in underserved communities. 'A well-trained internist can help offset the shortage of specialists by managing complex conditions at a high level. The true value of a primary care physician emerges when a patient's care requires coordination across multiple specialties. The ability to lead multidisciplinary care while keeping the patient and their family informed is what ultimately drives the best clinical outcomes and enhances patient satisfaction.' A Starting Point When a draft of AHIP's plan initially crossed my desk, I was skeptical. Voluntary reform isn't something that necessarily has a great track record in healthcare. And yet more than 50 plans (including my own) that provide coverage to tens of millions of Americans have signed on and made a public commitment to reform. After speaking to my physician colleagues and hearing their earnest frustrations, there's no doubt in my mind that the system needs reform and the association's proposals—which are not insubstantial and would address many of the problems —are a great place to start. After all, none of the physicians I spoke to are asking for a blank check. They're asking for a system that trusts their judgment, respects their time, and puts patients first. Reforming prior authorization isn't just about efficiency. It's about dignity—restoring it to the people who give care, and the people who need it—and AHIP's plan, acknowledging some of the challenges my physician colleagues face every day, is a meaningful step in the right direction.
Associated Press
11-02-2025
- Business
- Associated Press
SCAN's Chief Corporate Development Officer, Rona Li, recognized as one of Modern Healthcare's 40 Under 40
/ -- SCAN Group, a diversified not-for-profit healthcare company that operates SCAN Health Plan, one of the nation's largest and fastest growing not-for-profit Medicare Advantage health plans, is pleased to announce that its Chief Corporate Development Officer, Rona Li, was named one of Modern Healthcare's 40 under 40. This award recognizes the healthcare industry's rising stars age 40 and under who contribute to a culture of innovation and help their organizations achieve and exceed financial, operational, and clinical goals. 'I am honored to receive this recognition and to be among highly esteemed healthcare leaders who are aiming to improve healthcare for all,' said Li. 'I am grateful for the opportunity to support SCAN's mission to keep seniors healthy and independent and to enhance the not-for-profit healthcare experience for America's seniors.' 'Rona has the energy, discipline and passion to drive real impact in American healthcare over what will be a long and impactful career,' said Dr. Sachin H. Jain, CEO of SCAN Group and SCAN Health Plan. 'SCAN is fortunate to have someone with her high integrity and mission-alignment leading our corporate development efforts.' Growth and Investments At SCAN, Li oversees a diverse eight-figure portfolio encompassing venture investments from Seed through Series D, alongside majority-to-wholly-owned care delivery entities that are generating substantial growth. Here are some examples. • Welcome Health, SCAN's geriatric primary care medical group, is on track to serve over 3,000 members through the implementation of three new payer contracts and a practice acquisition, with another on the horizon for 2025. • Homebase Medical, SCAN's in-home care provider, has expanded into Arizona and has broadened its services to include chronic disease management, integrated behavioral health and palliative care. • MyPlace Health, SCAN's joint venture participating in the Program of All-Inclusive Care for the Elderly (PACE), opened its first center in downtown Los Angeles in 2024 and will open a second center in south Los Angeles in 2025. MyPlace Health anticipates membership growth that will exceed the typical first-year growth of most PACE programs. • Healthcare in Action, SCAN's integrative street medicine provider, has grown significantly since its inception and now operates in 18 California communities across six counties, providing comprehensive care to 8,400 individuals experiencing or at risk of homelessness. Enhancing Member Experience Under Li's guidance and leadership, SCAN is redefining member experiences by addressing the full spectrum of members' wants and needs. This initiative has resulted in new relationships with prominent consumer brands, offering SCAN members value-added benefits worth millions of dollars. These collaborations include caregiver support, a renowned clinical weight loss program, in-home massages, expedited travel security programs and consumer technology discounts. In addition to creating a more personalized, efficient and seamless healthcare journey for SCAN members, Li has established partnerships with organizations that provide enhanced experiences in the areas of digital member engagement, call center experience and medication management. Li has also spearheaded participation and strategy development of soon-to-be-announced joint ventures and partnerships that will bring not-for-profit Medicare Advantage (MA) healthcare to thousands of new customers in emerging markets. More information on this venture is set to be revealed in the spring of 2025. 'Whether it is working in an emergency department, behind the scenes developing smart AI tools or in so many of the other roles needed in healthcare today, the 2025 class of 40 Under 40 demonstrate a dedication to improving their organizations, the industry and access to medical care,' said Mary Ellen Podmolik, editor-in-chief of Modern Healthcare. 'Our honorees already are role models blazing trails and we look forward to seeing their career journeys progress in healthcare.' The profiles of all the honorees are featured in the February 10, 2025 issue of MH magazine and online at About SCAN SCAN Group, is a mission-driven not-for-profit organization dedicated to tackling some of the biggest issues in healthcare for older adults, including chronic illness, access to care, homelessness, inequities, and loneliness. SCAN Group's Medicare Advantage health plan, SCAN Health Plan, is one of the nation's foremost not-for-profit Medicare Advantage plans and serves over 294,000 members in California, Arizona, Nevada, Texas, and New Mexico. Independence at Home, a SCAN Health Plan community service, provides vitally needed services and support to seniors and their caregivers. Since 2020, SCAN has launched four mission-aligned medical groups*, including Healthcare in Action, Welcome Health, Homebase Medical and myPlace Health (a joint venture with Commonwealth Care Alliance), each of which focuses on meeting the needs of older adults. SCAN's care delivery affiliates collectively serve more than 30,000 members. To learn more, visit * Other medical groups are available in SCAN Health Plan's network About Modern Healthcare SCAN Group +1 5625086781 [email protected]
