This week's pledge Healthcare Industry and Ministry of Health and Human Services (HHS) The pre-authorization (PA) was a positive public relations message masked as a fundamental declaration of a game-changing policy commitment. In summary, the insurance company group is AHIP Blue Cross Blue Shield Association I agreed to address some topics:
Standardization of electronic pre-authentication
Reduce the scope of claims covered by prior permission
Ensures continuity of care when patients change plans
Improved communication and transparency in decisions
Enlarge real-time response
Ensure medical reviews for unapproved requests
There are critics of the PA process throughout the healthcare industry. Doctors, hospitals, patients, and care givers all have problems navigating their PA. Individually and together, they argue that it is opaque, unfair, reductive and burdensome. They allege that insurance companies conspired to limit access to care in order to pursue profits by setting excessively strict standards in determining whether to cover care or not.
To resolve this bitter argument, the above commitments allow us to argue that both sides are addressing concerns about the PA. but Is there really any realities in this agreement? let's We'll dig a little deeper to see if this contract represents a major change.
First, our commitment to standardization of electronic PAs, intended to be implemented by January 1, 2027, is based on common data and submission requirements, using the Fast Healthcare Interoperability Resource (FHIR®) application programming interface. This industry standard is a simple and reasonable path to some level of interoperability, but requires clearer adherence to long-term policies. Next, Consider reducing the scope of claims covered by prior approval and reducing the continuity of care between plans. While these could lead to an increase in services received in practice, changes to these policy could lead to an increased future denial of care that has not been approved and is not subject to new plan coverage. That is, the patient is on the hook for its care. Finally, standardization of electronic PAs may improve some communication and transparency in decisions that include real-time responses, and reduce some of the plays of waiting gaming providers and patients, but does not reduce PA denials or increase service coverage. People just get “yes” or “no” faster. And while it is nothing, it rarely addresses fundamental disagreements among healthcare professionals regarding the essential role of PAs.
And this is truly an important issue of the pledge between HHS and industry stakeholders. The list of actions does not provide a commitment to reducing the number of rejections patients receive. Reduce the number of rejections patients receive, prevent future rejections of pre-authentication requests outside the agreed transition period, reduce the cost of approved procedures or increase the number of eligible services.
The second point is that the contract is very similar to the 2018 PA Consensus statement It's obvious that they didn't move the needle as it was issued by a group of roughly the same people (at least the payer side) and talked again about the same issue in 2025. And it stands rationality: Not only willing to communicate more quickly about rejections, but not expanding coverage for these procedures is no longer covered by PA, but it is not a panacea for the problems facing the healthcare insurance industry.
However, there is another claim worth investigating. Is the US PA denial particularly excessive? Tell a story that Medicare Advantage (MA)'s PA rejection, the most cited example of PA issues, does not show exactly the system screaming for help. Based on Data analysis From KFF in the 2023 contract year, the overall rejection rate of claims was 6.4%, based on MA's claim denial, appeal and results. These rejections are not sorted by the validity of any type of service or denial, but at face value, this rate is one of the total MA PA submissions expected for a program of this size, and this rate is lower. Furthermore, of these PA denials, 81.7% have been overturned when appealed. The traditional Medicare PA review had a rejection rate of 27.6%, with only 28.7% of appealed rejections being overturned. It's not a complete apple vs. april comparison, but a PA process that's been exploited too seems to be a problem that certain industry segments can achieve that.
What can we learn from these data? The PA appeal process appears to be very effective in reverse the rejection of a claim, and improving that process is the path to further improve the PA and correcting false or excessive rejection. However, more generally, For all talks on advance approval, there are other more pressing issues in the scope of healthcare. Premium levels, deductions, out-of-pocket costs, transparency in price and coverage, healthcare professional availability, network validity, and claim denial (which could be a major issue with a decline in PA) are all independent and require more dramatic health insurance issues.
As a point of procedural order, the entire move was a voluntary agreement and was announced via a press release. This does not involve rulemaking, law, or enforcement mechanisms. There may be some rules that support these PA goals or have been enacted, but those rules existed. in front The announcement and PA were considered an issue requiring this industry contract.
Previous permissions are a very noticeable, very frustrating bottleneck. Particularly because it is perceived to stand between the patient and medically necessary care. PAs are boogie man of the problems healthcare faces, as they often allow patients, healthcare providers and payers to point their fingers at each other while they assert responsibility. This discussion writes a paper on real-life issues in healthcare, including service availability and affordability, the effectiveness of health interventions, and beyond (or below) regulations for various parts of the healthcare finance chain. Instead of relying on the weak glory of this announcement, the healthcare industry and policymakers should focus on practical, practical and influential reforms to the health insurance industry.
Chart Review: National Health Expenses Expected to Outperform Economic Growth in the Next 10 Years
Nicholas Montenegro, Health Policy Intern
June 25th, Centers for Medicare and Medicaid Services (CMS) opens National health expenditure forecast for 2024-2033. Survey results It may surprise many people as forecasts show a uniform trend before CMS estimate – This predicted that medical costs would continue to outperform economic growth over the next decade. This trend reflects increased demand for healthcare services, aging population, increased health costs, and a changing regulatory environment.
Overall healthcare costs have increased considerably since the Covid-19 pandemic, but annual growth rates are expected to continue to slow down varyingly Legislative clauses (Expanded healthcare scope and registration) It will expire. Healthcare spending is expected to increase by 7.1% in 2025, a marked decline from the estimated 8.2% growth in 2024. Furthermore, annual growth in national health spending is projected to average an average of 5.8% over the next decade. Simply put, the sundown of Covid-19 pandemic-related funds may indicate some decline in health spending, but the comprehensive trend still indicates significant future growth in national health spending.
As mentioned earlier, this growth is expected to exceed the average annual growth in GDP annually, with the national health spending share of GDP increasing to over 20% from 17.4% in 2022. The chart below shows significant growth in Medicare spending over the next decade, with a 154% increase from 2022 to 2033, followed by a 130% increase in Medicaid, 84% private insurance, and other health expenses (i.e., the 340B program and other health programs) increasing by 19%.
It is noteworthy that CMS estimates are not just about registration patterns and demand for healthcare services. Regulatory measures under consideration including Budget adjustment legislation Other health-related rules and laws may contribute to the acceleration or slowdown of national healthcare costs in the future. Furthermore, healthcare spending behaviors can be affected by macroeconomic conditions, including inflation and wage growth, which provides additional uncertainty.
