背景:事先授权审查(PAR),在美国,是一个最初旨在专注于住院和昂贵的高敏锐度护理的过程。随着时间的推移,付款人扩大了PAR的范围,包括影像学研究,处方,和常规治疗。PAR对医疗保健的潜在不利影响最近已成为人们关注的焦点,但其对骨科亚专科护理的影响尚不清楚.这项研究调查了拒绝率,护理延迟的持续时间,以及PAR对骨科亚专科护理的行政负担。
方法:前瞻性,进行了多中心研究,分析了PAR过程。在提供常规患者护理的过程中,来自六个州的骨科肩部和/或运动亚专业实践监测了付款人强制的PAR。保险公司(传统医疗保险,管理医疗保险,医疗补助,商业,工人补偿或政府付款人(即Tricare,VA),服务地点,批准/拒绝率,批准/拒绝的时间,和完成过程所需的管理时间都被记录和评估。
结果:在总共1,065个PAR请求中,我们发现,骨科亚专科医师推荐的高级影像学检查或手术的总拒绝率为1.5%(16/1065).与传统的医疗保险相比,商业和医疗补助保险的拒绝率很小,但在统计学上却显着较高。管理医疗保险,工人的补偿,或政府保险(p<0.001)。在单个PAR上花费的平均管理时间为19.5分钟,患者平均等待2.2天才能获得初始批准.管理医疗保险,商业保险,工人的补偿,与传统医疗保险或其他政府保险相比,医疗补助需要大约3到4倍的管理时间来处理PAR(p<0.001)。在控制付款人后,我们发现基于地理位置的批准/拒绝存在显著差异(p<0.001).上诉导致随后的拒绝率相对较低(20%)。然而,在最初提出请求后,大约三分之一的上诉仍处于悬而未决的状态,持续了30天或更长时间。
结论:这是迄今为止关于PAR对美国骨科亚专科护理影响的最大的前瞻性分析。当骨科专家推荐时,几乎所有PAR请求最终都获得批准,尽管需要大量的资源利用和延迟护理。当前的PAR实践构成了不必要的过程,增加了行政负担,并对获得骨科亚专科护理产生了负面影响。随着医疗保健转向基于价值的护理,PAR应该受到质疑,因为它似乎不会增加价值,但可能会对护理的成本和及时性产生负面影响。
BACKGROUND: Prior authorization
review (PAR), in the United States, is a process that was initially intended to focus on hospital admissions and costly high-acuity care. Over time, payors have broadened the scope of PAR to include imaging studies, prescriptions, and routine treatment. The potential detrimental effect of PAR on health care has recently been brought into the limelight, but its impact on orthopedic subspecialty care remains unclear. This study investigated the denial rate, the duration of care delay, and the administrative burden of PAR on orthopedic subspecialty care.
METHODS: A prospective, multicenter study was performed analyzing the PAR process. Orthopedic shoulder and/or sports subspecialty practices from 6 states monitored payor-mandated PAR during the course of providing routine patient care. The insurance carrier (traditional Medicare, managed Medicare, Medicaid, commercial, worker\'s compensation, or government payor [ie, Tricare, Veterans Affairs]), location of service, rate of approval or denial, time to approval or denial, and administrative time required to complete process were all recorded and evaluated.
RESULTS: Of 1065 total PAR requests, we found a 1.5% (16/1065) overall denial rate for advanced imaging or surgery when recommended by an orthopedic subspecialist. Commercial and Medicaid insurance resulted in a small but statistically significantly higher rate of denial compared to traditional Medicare, managed Medicare, worker\'s compensation, or governmental insurance (P < .001). The average administrative time spent on a single PAR was 19.5 minutes, and patients waited an average of 2.2 days to receive initial approval. Managed Medicare, commercial insurance, worker\'s compensation, and Medicaid required approximately 3-4 times more administrative time to process a PAR than to traditional Medicare or other governmental insurance (P < .001). After controlling for the payor, we identified a significant difference in approval or denial based on geographic location (P < .001). An appeal resulted in a relatively low rate of subsequent denial (20%). However, approximately a third of all appeals remained in limbo for 30 days or more after the initial request.
CONCLUSIONS: This is the largest prospective analysis to date of the impact of PAR on orthopedic subspecialty care in the United States. Nearly all PAR requests are eventually approved when recommended by orthopedic subspecialists, despite requiring significant resource use and delaying care. Current PAR practices constitute an unnecessary process that increases administrative burden and negatively impacts access to orthopedic subspecialty care. As health care shifts to value-based care, PAR should be called into question, as it does not seem to add value but potentially negatively impacts cost and timeliness of care.