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An Innovative Approach to Pre-Authorization At Mass General Hospital

April 3, 2014
by Rajiv Leventhal
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Application aims to promote appropriate use and cut costs related to pre-authorization and unnecessary surgical procedures
Creagh Milford, D.O.

Healthcare spending in the U.S. is widely deemed to be growing at an unsustainable rate, and efforts are being made by policymakers to seek ways to slow that growth or reduce spending overall. A key target is eliminating waste—spending that could be eliminated without harming consumers or reducing the quality of care that people receive and that, according to the most liberal estimates, may constitute up to one-third of all U.S. health spending, amounting to hundreds of billions of dollars every year.

According to Creagh Milford, D.O., at the Boston-based Massachusetts General Hospital (MGH), demands placed on doctors in the clinic today such as meaningful use are challenging enough, but demands from payers or purchasers to actually provide data on the appropriateness of physician procedures to avoid the idea that doctors are overusing measures—and thus causing harm to patients—also exist.

Milford is an associate medical director at Partners HealthCare in Boston, a health system with two academic medical centers—MGH and Brigham and Women’s Hospital—with 6,000 doctors across the enterprise. There, he says, Partners has taken on financial risk throughout the system, and that includes assessing risk of a procedure before it’s done. The payers and purchasers of healthcare “are asking us to prove its level of appropriateness before we do it,” says Milford.  “There are few ways to do that other than using clinical decision support tools that help pre-populate many answers for the clinicians in a way that makes sense for their workflow.”

Certainly, CDS tools that enable physicians and nurses at the appropriate point of the clinical workflow to have access to both structured as well as unstructured clinical data, can help solve significant problems that exist today. Enter a clinical insights platform developed jointly by the Boston-based QPID Health, MGH, and the Massachusetts General Hospital Physicians Organization (MGPO). QPID Health recently announced the release of the procedure decision support application Q-Guide, which addresses the need for providers to ensure appropriate procedures in order to improve patient care and reduce healthcare costs.

Used during the pre-operative decision making process, the application aims to help clinicians apply complex guidelines-based decision criteria to each patient's individual profile, and generates a recommended approach and risk score. Measurement of procedurally appropriate use is a strategic imperative for providers in an era of increasing provider accountability for improving quality while reducing the costs of care, according to QPID Health officials.

Q-Guide uses decision-making algorithms that are driven by combining the patient's clinical evidence with the latest guidelines and personalized risk models.  The first release of the software includes guidelines for high cost, high use and resource-intensive vascular, cardiac, and orthopedic surgical procedures. It can be accessed via a Web browser and is hosted in the cloud or in a client/server configuration, officials say. The platform integrates with electronic health records (EHRs) and other data repositories to extract the essential patient narrative from data scattered throughout the health record.

Q-Guide also can reduce the requirement for costly prior authorization, a labor-intensive process in which payers approve procedures in advance. Often, prior authorization imposes a heavy administrative burden for both payers and healthcare providers, notes Milford. “This process often requires the doctor who is recommending the procedure to reach out and have a conference call with another doctor in another state who might not even see patients anymore. And that doctor might say the procedure is inappropriate for whatever reason. That has happened to us frequently, and it’s frustrating for doctors because they want to be in the operating room, not on the phone explaining their reasons for proceeding with a procedure when they have already told the patient that it’s the right thing to do,” Milford says.

But within Partners HealthCare, Milford continues, the system is piloting the use of Q-Guide as its own ‘prior authorization’ mechanism. If procedures are performed and completed through the tool, Partners now has a waiver from two insurance companies to be able to waive any prior authorization once the procedure is booked, Milford explains.

“We see this as a huge win for our doctors, because they aren’t dealing with those hassles anymore. One doctor— an orthopedic spine surgeon—told me that for certain payers (who will go unnamed), he would have to tell a patient that he or she is totally appropriate for this procedure, but the insurers won’t sign off on it and will try to cancel the patient’s surgery. That is just unbelievable,” Milford says. “We think the doctors know best; they have the information and patient in front of them, and tools that standardize the decision making,” he says, adding that this method  goes way beyond what the payers require to determine appropriateness, which is often only crude criteria. “We feel that is ludicrous, and now that we own this problem of overuse, if we do indeed overuse, our shared savings are diminished. So let us take the burden of addressing prior authorization as opposed to the payer.”

MGH has been using the Q-Guide tool for about two years, as it was originally piloted for 150 clinicians in the hospital. In that time, Q-Guide has expedited the management of over 1,100 procedures during the first 18 months of adoption, Milford reports. “Diminishing the number of inappropriate procedures and having a high rate of appropriateness is a phenomenal story,” he says. “Before having tools like this in place, these efforts were done in a chart-by-chart review to prove appropriateness, and that’s not a sustainable or scalable model.”