Reforming prior authorizations, developing value-based reimbursement models, and increasing patient health literacy are top priorities for an AMA-Anthem partnership in 2018.

The American Medical Association (AMA) and Anthem, Inc. recently announced that they will work together over the next year to streamline prior authorization requirements and improve the healthcare experience overall through provider and payer collaboration.

“Physicians caring for patients across the country have many ideas about how we can reduce healthcare costs and administrative burdens while improving clinical outcomes, and we need the collaboration of Anthem and all health plans to implement those strategies,” stated Gerald E. Harmon, MD, AMA Board Chair. “The AMA looks forward to finding common ground on ways to improve the delivery of affordable, high-quality, patient-centered care.”

The industry heavy-hitters intend for the partnership to advance prior authorization priorities detailed in a consensus statement earlier this year.

The statement issued by the AMA called for payers and other healthcare leaders to implement selective application of prior authorizations. Payers should reduce prior authorization requirements for healthcare providers that demonstrate high-performance on quality measures and adherence to evidence-based medicine.

Providers in risk-based payment contracts should also face reduced prior authorization requirements to ensure timely, continuous care.

Prior authorization requirements should always support continuity of patient care, the AMA added in the statement. Prior authorizations, as well as formulary or treatment coverage changes, can disrupt patient care. Therefore, payers and healthcare leaders should minimize repetitive authorizations and develop care continuity protections for patients undergoing an active course of treatment when the formulary or treatment coverage changes.

The consensus statement also called for increased automation of prior authorization processes, increased communication between all stakeholders, and frequent reviews of medical services and prescription drugs subject to prior authorizations.

The American Hospital Association (AHA), America’s Health Insurance Plans (AHIP), American Pharmacists Association (APhA), Blue Cross Blue Shield Association (BCBSA), and Medical Group Management Association (MGMA) supported the consensus statement.

Now, the AMA hopes for Anthem to implement the prior authorization reforms outlined in the consensus statement.

The industry group also aims for one of the nation’s largest payers to help develop value-based reimbursement models for specialty and primary care physicians.

Value-based reimbursement models have the potential to achieve the Quadruple Aim, which calls on the healthcare system to improve patient outcomes and care access, reduce total costs of care, and improve patient and healthcare professional satisfaction.

However, value-based reimbursement adoption has lagged, especially in the commercial space. While medical groups anticipate 60 percent of federal revenue to stem from an alternative payment model by 2019, the groups only expect 37 percent of commercial revenue to come from similar value-based reimbursement models, a recent AMGA survey showed.

Value-based reimbursement from federal revenue is projected to grow faster than commercial payments because medical groups have less access to alternative payment models in the private sector. About 17 percent of respondents reported having no access to commercial risk-based plans in 2017 and another 41 percent stated less than one in five plans in their markets offered risk-based products.

By supporting greater collaboration with providers and payers, Anthem and the AMA intend to reverse this trend and implement value-based reimbursement models for all providers. The groups also plan to improve existing models.

Other priorities for the AMA and Anthem partnership in 2018 include advancing patient health literacy and improving access to timely, actionable data.

At the heart of the partnership is collaboration, the groups emphasized. The AMA and Anthem pointed out that provider and payer collaboration will be the key to meeting the goals of their partnership and improving the healthcare experience for all stakeholders.

“Collaboration between payers and health care professionals is critical in order to evolve and advance our healthcare system to one that is simpler, more accessible and more affordable for consumers,” stated Craig Samitt, MD, Anthem’s Chief Clinical Officer. “At Anthem, we value our relationships with healthcare professionals, and today we are reaffirming our commitment to work together to create a best-in-class health care system that delivers on this promise for patients across the country.”

Source: RevCycle Intelligence (Mar. 7, 2018)