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Are payers ensuring good patient care?


One of the missions of health insurance providers is to ensure patients have access to effective, quality, evidence-based care. Clinical practice guidelines support the practice of evidence-based medicine, and are typically derived from recognized scientific sources such as specialty societies and are updated annually.

One of the missions of health insurance providers is to ensure patients have access to effective, quality, evidence-based care. Clinical practice guidelines support the practice of evidence-based medicine, and are typically derived from recognized scientific sources such as specialty societies and are updated annually. 

The guidelines are intended as a point-of-reference, or framework, to assist physicians and other clinicians in diagnosis and management of selected conditions. Of chief importance is that payee medical directors follow prior authorization and clinical guidelines to work with physicians on providing the best care.

Virginia Calega, MD, vice president of medical management and policy for Independence BlueCross, Philadelphia, Penn., says when insurers look at what they want to prioritize, the intent is not to create a barrier to access of care.

“It’s a thoughtful process where you look at data, you talk with other payers to understand how they are performing the realization management process,” she says. “In the data, you’re looking for unwarranted variation in the delivery of care-services where there is a high likelihood of people perhaps not following evidence-based guidelines.”


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Tricia Baird, MD, FAAFP, medical director with Priority Health, Grand Rapids, Mich., says that in the same way that clinical guidelines describe best practices in medical care with the goal of reducing unwarranted variation in care, Priority Health focuses policies around prior authorization on areas not as strictly defined.

“The clinical events we request prior authorization for are those where overuse is prevalent, clinical options have similar clinical efficacy and very different total costs of care, or the requested treatment doesn’t have sufficient published evidence of safety and efficacy,” she says. “These three use cases all involve unwarranted cost variation in the care that is provided.”

To ensure best care, Priority Health updates its policies annually and reviews them with its Medical Advisory Committee, a representative of its network physicians by specialty, geography and experience.

“They ensure we’re applying evidence-based medicine with updated published evidence, and that we balance practice concerns with the need to provide care in the most cost-effective way possible,” Baird says. “We also meet regularly with other geographic and specialty groups of physicians to explore hot topics and emerging standards of care.”

Kate Berry, MPP, senior vice president of clinical affairs with America’s Health Insurance Plans, an insurance industry trade group, notes health insurance providers typically notify physicians and hospitals about new or updated guidelines via their credentialing/re-credentialing letters and in physician newsletters periodically.

Next: Challenges for physicians


“Guidelines may not apply to every patient or clinical situation; some variation from guideline is expected,” she says. “Patients deserve quality, affordable and effective care. Clinical guidelines help ensure consistency in treatment, and that patients are receiving the right care for them at the right time. Provider judgment and knowledge of an individual patient supersedes clinical guidelines.”

Challenges for Physicians

Payer prior authorizations add time to the clinical journey from diagnosis to completed care. To prevent delay in care, Baird notes the company works to transfer more control to its physician partners.


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“Shared risk arrangements give physicians aligned interest to look for unwarranted care variation and allows them more control in clinical decision making,” she says. “We continue to have robust conversations with our network partners to help them understand their clinical and financial performance. We believe this puts physicians in the driver’s seat, where they should be when it comes to balancing the many decisions that must be made to deliver evidence-based, cost-efficient medicine.”

A provider’s detailed system allows for innovations like embedding preferred formularies into EHRs. When a physician can see tiered alternatives at the point of prescribing, the fastest, highest value choices can be made at the point of care.

“Patients and physicians want to focus on the clinical encounter,” Baird says. “It is much less intrusive to program an EHR system to serve up relevant choices for the particular case at hand rather than work through the decision-making process from scratch every time. A predictable method can take some frustration out of the work.”

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© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health