Last Week in Healthcare: AHIP vs NYT vs AMA, Key New Drug Approvals

Prior Auth Matchup: NYT vs AHIP

The New York Times' video opinion, "What's My Life Worth? The Big Business of Denying Medical Care," on prior authorization garnered significant attention after being released on Thursday.

• AHIP's Perspective: AHIP defended the role of prior authorization in ensuring evidence-based care while managing costs. They stated that coverage decisions follow recommendations from medical societies, experts, and federal authorities to promote patient safety and outcomes.
• Call for Balance: AHIP encouraged a balanced view of the cost and quality challenges in healthcare, citing the $935 billion burden from waste and inappropriate care.
• Streamlining Processes: AHIP emphasized the need for seamless prior authorization processes and encouraged providers to adopt technology for timely coordination of patient care.

This debate highlights the growing demand from various stakeholders for streamlined and efficient prior authorization processes.

Read the full AHIP Letter to the Editor:

The Times’ video exploits tragic outcomes and ignores basic and important facts about the limited yet key role of prior authorization in ensuring patients get evidence-based care, while keeping care as affordable as possible. Prior authorization is used for a limited number of medical services – most often for treatments, tests and certain medications that are high-cost and/or high-risk. Coverage decisions for treatments, surgeries or procedures follow clinical recommendations from leading medical societies, clinical experts and federal health authorities. In cases where prior authorization is used, it’s designed to ensure clinical care aligns with evidence-based recommendations – not to deny or discourage patients from getting the care they need. Health plans are constantly evaluating coverage policies as new evidence emerges, and where the data on patient safety and outcomes are proven, the use of prior authorization has fallen sharply. The approval process needs to be seamless for all parties, and health plans have broadly implemented electronic processes and review. We encourage all providers to adopt the basic technology needed to ensure timely coordination on patient care. Despite efforts to advance evidence-based medicine, consumers still bear a staggering $935 billion cost burden from waste and inappropriate care. Furthermore, 87% of doctors have reported negative impacts from low-value care. Ignoring those facts does a disservice to readers and those actively looking for balanced consideration of the significant cost and quality challenges in our health system.

Continued Controversy on Change Healthcare Cyberattack

The President of AMA, Jesse M. Ehrenfeld, MD, MPH, released this statement on AHIP’s response to the Change Healthcare Cyberattack and referenced the current administration's emphasis on Prior Authorization. It highlights how important improving PA processes is to reduce friction among payers and providers.

Medicare Updates and Drug Approvals

Significant changes are on the horizon for Medicare's utilization management (UM) tools, while new drug approvals from pharmaceutical giants have garnered attention:

• Lilly's Weight Loss Drug: Eli Lilly's Zepbound, a lower-cost alternative to Novo Nordisk's Wegovy, has been approved for weight loss.
• Novo Nordisk's Diabetes Pill: Rybelsus received FDA approval as an initial treatment to lower blood sugar levels, expanding treatment options.
• Weight Loss Market Potential: The weight loss market could reach $100 billion by 2035, making it a lucrative area for pharmaceutical companies.

Where do we go from here?

The prior authorization debate underscores the need for a balanced approach that considers both patient access to appropriate care and responsible management of healthcare costs. As new treatments emerge, effective utilization management strategies will be crucial to ensure their appropriate and economical use.

Payers and providers must collaborate to streamline prior authorization processes, leveraging technology (like AI) and adhering to evidence-based guidelines.

Ultimately, a well-functioning healthcare system requires the alignment of all stakeholders – payers, providers, pharmaceutical companies, and policymakers – to address the challenges of cost, quality, and access. Data-driven decision-making and new technologies like AI have the potential to catalyze significant progress towards this goal.

How do you interpret these developments regarding prior authorization?