Private Payers
Private payers are pivotal in shaping and influencing healthcare systems. The U.S. Surgeon General’s Advisory, Addressing Health Worker Burnout, outlines the evidence for private payers’ involvement in improving workload and workflows in healthcare and recommends health insurance companies and payers can:
- Move to payment models that support both the quality and quantity of time that health workers spend with patients
- Reduce administrative burden posed by prior authorization requests, documentation, and other reporting requirements
- Ensure workers have access to quality mental health and substance use care by ensuring parity in mental health coverage and adequacy of mental health and substance use providers, and expanding telehealth coverage
- Partner with health care delivery organization to improve clinical care and preventive services
Resources
The National Academy of Sciences, Engineering, and Medicine (NASEM) report on Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care provides recommendations for payment reform including shifting primary care payment toward hybrid (part FFS, part capitated) models that pay prospectively, are risk-adjusted for medical and social complexity, allow for investment in team development and practice transformation, and align incentives for improving patient outcomes.
eHealth Initiative convened a series of stakeholder meetings in 2018 and 2019. Their report, Considerations for Improving Prior Authorization in Healthcare, provides recommended practices to improve the current prior authorization environment: 1) using transparency of payer policy and evidence-based clinical guidelines, 2) reducing overall volume of services and drugs requiring prior authorization, 3) incorporating electronic standards to improve the process, 4) exploring alternative payment models that bundle authorizations
The American Medical Association provides resources to reform prior authorization, including:
- Consensus Statement on Improving the Prior Authorization Process offers five areas of opportunity: 1) selective application of prior authorization, 2) prior authorization program review and volume adjustment, 3) transparency and communication, 4) continuity of patient care, and 5) automation to improve transparency and efficiency
- Measuring progress in improving prior authorization
America’s Health Insurance Plans (AHIP) provides a list of actions health insurance providers are taking to improve mental health coverage. Examples include:
- Blue Cross and Blue Shield of Texas added nearly 4,000 in-network behavioral health providers through a company called Headway which helps connect individuals with appropriate mental health providers, both in-person and via telehealth. They also provide grants across Texas to address gaps in behavioral health care
- The Health Care Service Corporation is expanding a maternal support program to develop new service models and add community supports for women and babies.
