Each Wonks’ Corner, a member of Blue Shield’s government affairs team dives into a current policy topic. See our previous Wonks’ Corner blogs here.
Prior authorization. These two words trigger a lot of negative emotions from consumers and everyone working in the healthcare delivery system. That's why reforming the process is top of mind for policymakers in Washington DC and statehouses across the country. Like many others, Blue Shield of California believes the process must change. While important in its purpose, prior authorization must be more efficient for consumers and industry. The catalyst for needed reform lies in the potential of real-time clinical data sharing.
For the first time in California, the health care system will be required to share clinical information in real time under the state's Data Sharing Agreement (DSA). This advancement can transform prior authorization, deliver better health outcomes, and drive higher value for consumers.
From the outside, it may be hard to see why data sharing is vital to reforming prior authorization. At its core, the prior authorization process relies on communicating healthcare data between payers and providers. Often, the information is incomplete, transmitted manually, and largely reliant on partial views of a patient's medical history.
This process exists for many important reasons, including ensuring that providers follow established medical policies and drive higher value. Still, there is no reason it has to happen in such an inefficient, byzantine process.
Embracing the state Data Sharing Agreement by industry is step one. As the Data Sharing Agreement requires, real-time clinical data sharing will improve prior authorization by enabling the immediate exchange of patient information, treatment plans, and medical histories among healthcare providers, payers, and regulators. Its value lies in enhancing prior authorization processes' efficiency, accuracy, and transparency.
Perhaps most importantly, real-time data sharing expedites decision-making. With instant access to comprehensive patient records, providers and health plans can swiftly assess the necessity of a procedure or treatment, reducing wait times and minimizing potential health risks. Appropriateness of care will improve, and the system will cause less headaches.
Moreover, real-time data sharing improves the accuracy of authorization requests. It enables all relevant parties to access up-to-date information on a patient's medical history, including current diagnoses, medications, and previous treatments. This ensures that requests align with evidence-based guidelines, reducing the likelihood of unnecessary procedures or treatments.
Additionally, it fosters collaboration among healthcare stakeholders. By seamlessly connecting healthcare providers, payers, and regulators, real-time data sharing promotes a unified approach to patient care. This collaboration can lead to more informed decisions, better outcomes, and a more cost-effective healthcare system.
Furthermore, real-time data sharing enhances transparency and accountability. It allows for a clear audit trail, documenting every step of the prior authorization process. This transparency builds trust among stakeholders and provides a foundation for continuous quality improvement and regulatory compliance.
In the context of prior authorization reform, this technology-driven approach addresses some of the most pressing issues in healthcare, including administrative burden, cost containment, and patient satisfaction. The industry can streamline processes, reduce costs, and prioritize patient well-being by leveraging real-time clinical data sharing.
It's clear the prior authorization process must change, but doing so means the industry must embrace California's Data Sharing Agreement and make real-time clinical data sharing a reality. Undoubtedly, this will expedite decision-making, improve accuracy, foster collaboration, and enhance transparency, making it an essential tool for modernizing and optimizing our healthcare system.