By Dr. Alexander Choi
After two decades as a physician, a local elected official, the board chairman of a large private practice physician organization, and now a patient fighting cancer, I’ve seen our healthcare system from every angle — I know what works, and what needs fixing.
That’s why I’m speaking up now because some of the conversation around prior authorization (PA) at the Statehouse is missing the point.
Prior authorization often gets a bad reputation. But its original purpose was — and still can be — to protect patients, support physicians, and keep healthcare affordable. It was designed to ensure that care is medically necessary and that physicians are guaranteed payment and also fairly reimbursed. As someone who’s practiced in both small and large private settings and in large hospital systems, I’ve seen how critical that assurance can be — especially for independent physicians.
But like many good ideas in healthcare, PA has grown complicated, and some have argued that it has lost its original intent. The process can feel like a battle between physicians and payers, and that can be frustrating for physicians and patients alike. As we debate anything in healthcare, we also have to be cognizant about physician and staff burnout.
Still, I don’t believe we fix that by eliminating PA altogether. We need to reform it, not repeal it.
Currently, I’m participating in meetings between Anthem and a limited number of physicians representing the Indiana Physicians Health Alliance (“IPHA”), a membership-based alliance of Indiana medical practices representing almost 700 independent physicians who are the sole owners of their medical practices. The project is a “demonstration project” with the goal of limiting the PA to only those limited and select medical services that truly makes sense to have a PA for, and to remove the PA for the majority of medical services that do not warrant getting a PA for.
Instead of blanketing all care with the same requirements, this demonstration project between the IPHA and Anthem will use evidence-based clinical data and a trust-based model between the payer and the physician(s) to reduce unnecessary reviews. The concept makes sense and could reform the PA process on a much larger scale amongst all physician practices in Indiana.
Current pending legislation in the Indiana Statehouse is also proposing legislation to streamline and make the PA process faster, more efficient, and more focused on where it’s truly needed.
The collaborative process between the IPHA physicians and Anthem is showing that physicians and payers can come together and work thru their differences to get to the same outcome and results. It’s still a work in process but, more importantly, it’s proving that collaboration between physicians and insurers is not only possible, but productive.
