Transforming Utilization Management

In our zeal to address medical waste we have added to administrative waste. Now we are doing something about it. 

Understanding Waste

With healthcare costs growing year over year, waste in the healthcare system is an urgent and major issue that must be addressed. EviCore is in the business of combating waste in the provision of medical care. Our work is focused on making sure that patients get only those tests and procedures that they actually need, and avoid those that can needlessly cause harm.

While medical costs are one type of waste, administrative waste also burdens our healthcare system. According to data published in a recent Health Affairs blog post, 20-25% of total healthcare waste ($700B) is administrative or operational, while 14-15% ($445B) is clinical. 

That's why we are committed to changing prior authorization into a streamlined process that delivers approvals in real- time to the provider workflow. 

Figure 1. Causes of Waste in the U.S. Healthcare System

Source:https://www.healthaffairs.org/do/10.1377/hblog20180530.245587/full/

Clinical waste accounts for $445 billion a year in healthcare spending in the United States. Most clinical waste stems from poor-quality execution in delivery, inefficient care coordination, and overspending on tests and procedures. 

Administrative waste accounts for $700 billion a year in spending. A good deal of this can be traced to inefficiency and excess bureaucracy involved in hospital administration, in billing procedures, and in interactions with insurance companies. 

From a provider or staff viewpoint, the prior authorization process may feel like part of administrative waste.Concern about wasting time waiting for decisions, and the need to reschedule because the prior authorization is still pending, can be challenging. 

Additional pain points include:

• The costs associated with prior authorization
• Manual submission of requests and any additional clinical information needed by the medical reviewer, which is time consuming and can lead to errors
• Consulting multiple data sources to stay abreast of continually changing payer rules.

EviCore recognizes that traditional prior authorization can impose a burden on individual providers and the patients and organizations they serve. Our goal is to transform prior authorization so that it supports the delivery of evidence-based care without adding to administrative waste that burdens our healthcare system. To that end, we have launched EviCore intelliPath^®, a real-time prior authorization automation solution that streamlines the way providers can submit and track cases. Using technology innovations such as data science, machine learning, and NLP along with EHR integration, we are addressing waste head on. In this space we'll soon be sharing more about this and other initiatives we'll be launching to combat waste in the healthcare arena.