PDF(Pubmed)
Abstract：
To measure and compare the scope of US insurers\' policies for prior authorization (PA), a process by which insurers assess the necessity of planned medical care, and to quantify differences in PA across insurers, physician specialties, and clinical service categories.
Cross sectional analysis.
PA policies for five insurers serving most of the beneficiaries covered by privately administered Medicare Advantage in the US, 2021, as applied to utilization patterns observed in Medicare Part B.
30 540 086 beneficiaries in traditional Medicare Part B.
Proportions of government administered traditional Medicare Part B spending and utilization that would have required PA according to Medicare Advantage insurer rules.
The insurers required PA for 944 to 2971 of the 14 130 clinical services (median 1899; weighted mean 1429) constituting 17% to 33% of Part B spending (median 28%; weighted mean 23%) and 9% to 41% of Part B utilization (median 22%; weighted mean 18%). 40% of spending ($57bn; £45bn; €53bn) and 48% of service utilization would have required PA by at least one insurer; 12% of spending and 6% of utilization would have required PA by all insurers. 93% of Part B medication spending, or 74% of medication use, would have required PA by at least one Medicare Advantage insurer. For all Medicare Advantage insurers, hematology and oncology drugs represented the largest proportion of PA spending (range 27-34%; median 33%; weighted mean 30%). PA rates varied widely across specialties.
PA policies varied substantially across private insurers in the US. Despite limited consensus, all insurers required PA extensively, particularly for physician administered medications. These findings indicate substantial differences in coverage policies between government administered and privately administered Medicare. The results may inform ongoing efforts to focus PA more effectively on low value services and reduce administrative burdens for clinicians and patients.
Cross sectional analysis.
PA policies for five insurers serving most of the beneficiaries covered by privately administered Medicare Advantage in the US, 2021, as applied to utilization patterns observed in Medicare Part B.
30 540 086 beneficiaries in traditional Medicare Part B.
Proportions of government administered traditional Medicare Part B spending and utilization that would have required PA according to Medicare Advantage insurer rules.
The insurers required PA for 944 to 2971 of the 14 130 clinical services (median 1899; weighted mean 1429) constituting 17% to 33% of Part B spending (median 28%; weighted mean 23%) and 9% to 41% of Part B utilization (median 22%; weighted mean 18%). 40% of spending ($57bn; £45bn; €53bn) and 48% of service utilization would have required PA by at least one insurer; 12% of spending and 6% of utilization would have required PA by all insurers. 93% of Part B medication spending, or 74% of medication use, would have required PA by at least one Medicare Advantage insurer. For all Medicare Advantage insurers, hematology and oncology drugs represented the largest proportion of PA spending (range 27-34%; median 33%; weighted mean 30%). PA rates varied widely across specialties.
PA policies varied substantially across private insurers in the US. Despite limited consensus, all insurers required PA extensively, particularly for physician administered medications. These findings indicate substantial differences in coverage policies between government administered and privately administered Medicare. The results may inform ongoing efforts to focus PA more effectively on low value services and reduce administrative burdens for clinicians and patients.
摘要：
目的：为了衡量和比较美国保险公司事先授权（PA）保单的范围，保险公司评估计划医疗必要性的过程，并量化保险公司之间的PA差异，专科医师,和临床服务类别。
方法：横断面分析。
方法：为美国私人管理的MedicareAdvantage覆盖的大多数受益人提供服务的五家保险公司的PA政策，2021年，适用于MedicareB部分中观察到的使用模式。
方法：传统MedicareB部分中的30540086受益人。
方法：根据MedicareAdvantage保险公司规则，政府管理的传统MedicareB部分支出和使用的比例。
结果：保险公司要求在14130项临床服务中的944至2971项（中位数为1899；加权平均值为1429）占B部分支出的17％至33％（中位数为28％；加权平均值为23％）和B部分利用率的9％至41％（中位数为22％；加权平均值为18％）。40％的支出（570亿美元；450亿英镑；530亿欧元）和48％的服务利用率将需要至少一家保险公司的PA；12％的支出和6％的利用率将需要所有保险公司的PA。93%的B部分药物支出，或74%的药物使用，至少有一家MedicareAdvantage保险公司会要求PA。对于所有MedicareAdvantage保险公司，血液学和肿瘤学药物占PA支出的最大比例（范围27-34％；中位数33％；加权平均30％）。PA费率在各专业之间差异很大。
结论：美国私人保险公司的PA政策差异很大。尽管达成了有限的共识，所有保险公司都广泛要求PA，特别是医生服用的药物。这些发现表明，政府管理的医疗保险和私人管理的医疗保险在覆盖政策方面存在巨大差异。结果可能会告知正在进行的努力，以更有效地将PA集中在低价值服务上，并减轻临床医生和患者的行政负担。
方法：横断面分析。
方法：为美国私人管理的MedicareAdvantage覆盖的大多数受益人提供服务的五家保险公司的PA政策，2021年，适用于MedicareB部分中观察到的使用模式。
方法：传统MedicareB部分中的30540086受益人。
方法：根据MedicareAdvantage保险公司规则，政府管理的传统MedicareB部分支出和使用的比例。
结果：保险公司要求在14130项临床服务中的944至2971项（中位数为1899；加权平均值为1429）占B部分支出的17％至33％（中位数为28％；加权平均值为23％）和B部分利用率的9％至41％（中位数为22％；加权平均值为18％）。40％的支出（570亿美元；450亿英镑；530亿欧元）和48％的服务利用率将需要至少一家保险公司的PA；12％的支出和6％的利用率将需要所有保险公司的PA。93%的B部分药物支出，或74%的药物使用，至少有一家MedicareAdvantage保险公司会要求PA。对于所有MedicareAdvantage保险公司，血液学和肿瘤学药物占PA支出的最大比例（范围27-34％；中位数33％；加权平均30％）。PA费率在各专业之间差异很大。
结论：美国私人保险公司的PA政策差异很大。尽管达成了有限的共识，所有保险公司都广泛要求PA，特别是医生服用的药物。这些发现表明，政府管理的医疗保险和私人管理的医疗保险在覆盖政策方面存在巨大差异。结果可能会告知正在进行的努力，以更有效地将PA集中在低价值服务上，并减轻临床医生和患者的行政负担。
