Navigating the Surge in Utilization Management and Prior Authorization
Dr. Amar Rewari explores the rise of utilization management and prior authorization in oncology, offering strategies to balance clinical operations with healthcare economics.
If you work in oncology today, you know the drill. You have a patient with a confirmed diagnosis, a clear staging report, and a guideline-concordant treatment plan. You are ready to start, but then you hit the wall: Prior Authorization.
As a radiation oncologist and Chief of Radiation Oncology at Luminis Health, I see the clinical impact of these delays daily. Patients are anxious; they want to start treatment yesterday. But as a physician executive with an MBA and background in healthcare finance, I also recognize the macro-economic pressures driving payers to pull these levers.
We are currently witnessing a massive surge in utilization management (UM). It is no longer just about high-cost drugs; it has permeated every layer of care delivery. Navigating this landscape requires us to bridge the gap between clinical necessity and economic reality.
The Perfect Storm
Why are we seeing this spike now? It is a convergence of several factors. Healthcare costs are continuing to rise, and payers—particularly in the Medicare Advantage space—are under immense pressure to control spend.
However, the mechanism of control has shifted. We are seeing a move toward algorithmic denials and the use of Artificial Intelligence in utilization management. I recently explored this as a panelist at the Cancer Support Community Utilization Management Summit. While technology should streamline approvals for standard care, it often acts as a "black box," generating denials for necessary treatments based on rigid criteria that fail to account for patient nuance.
Moving From Volume to Value
The friction caused by prior authorization is a symptom of a broken fee-for-service model. When volume drives revenue, payers use administrative hurdles as a blunt instrument to throttle that volume.
This is why I have dedicated much of my work with ASTRO and the Health Policy Council to value-based care reforms, such as the Radiation Oncology Case Rate (ROCR) model. If we can move toward payment models that prioritize outcomes and episode-based care rather than per-fraction billing, we remove the incentive for "over-treatment." In turn, providers should be granted relief from the administrative burden of prior auth.
Strategies for the Modern Physician Leader
So, how do we navigate this surge right now?
Leverage Data, Not Just Emotion: We must arm our peer-to-peer reviews with hard data. My background in financial analysis and policy has taught me that payers speak the language of economics and evidence. We must prove that the appropriate care is also the most cost-effective care in the long run.
Advocate for "Gold Carding": We need to push for policies where providers with a track record of adherence to evidence-based guidelines are exempted from routine prior authorizations. This allows health plans to focus their resources on outliers without penalizing high-quality physicians.
Engage in Policy Reform: We cannot just complain in the breakroom. Whether it is through societies like ASTRO or broader coalitions, we must engage with policymakers to regulate transparency in AI algorithms and utilization management.
The Bottom Line
Our goal must be to bridge medicine, management, and mission. We cannot ignore the financial realities of healthcare, but we also cannot allow administrative burdens to sever the bond between doctor and patient.
By understanding the economics behind the denials and advocating for structural payment reform, we can design a system that remains financially sustainable without losing its soul.
Interested in hearing more about the intersection of healthcare finance and policy? Tune in to my podcast, Value Health Voices, where we dive deeper into these issues.
