Providers Laud Prior Authorization Rule, EHRs Can Lower Provider Burnout

January 25, 2024 - Providers were encouraged by the new CMS rule on prior authorizations, which holds payers to a higher standard on prior authorization denials, transparency, and timing.

The new rule, which CMS approved on January 17, 2024, regulates the turnaround time for payers' prior authorization decisions. It also requires HL7 FHIR Prior Authorization API uptake to enforce automation efforts. Providers praised the rule which they said will improve patients' access to care.

Additionally, there has bee plenty of evidence to show that electronic health records (EHRs) can add to provider burdens, but a KLAS report indicated proper EHR implementation early on in a provider's career can reduce provider burnout. Meanwhile, hospitals like MGH continue to struggle with overcrowding and patient boarding as a result of the COVID-19 pandemic and the World Health Organization (WHO) published guidelines for generative AI use in healthcare. 

Kyle Murphy: Hello and welcome to Healthcare Strategies. Today's episode:

• WHO recommends guidelines for Gen AI
• MGH Acknowledges Boarding, Overcrowding in the ED
• Progress Being Made on Physician Burnout
• Providers Praise CMS on Prior Auths Provision.

This is Kyle Murphy, vice president of editorial at Xtelligent Healthcare, and I am joined as always by Kelsey Waddill.

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Kelsey Waddill: Hello.

Kyle Murphy: Hi, Kelsey.

Kelsey Waddill: Hi.

Kyle Murphy: How are you doing today?

Kelsey Waddill: Good.

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Kyle Murphy: The longest year ever. And it's only January....

Kelsey Waddill: Yeah. Oh no...

Kyle Murphy: These are exciting times if you're in politics because there's a lot of voting going on in the primary season, but I can tell you right now, I'm already done with all the political ads everywhere and the text messages that apparently come to my phone.

Kelsey Waddill: Oh, yes. Oh, yes.

Kyle Murphy: It's not that I'm against politics, it's just that I like to choose when and where these interactions take place.

READ MORE: How Artificial Intelligence, Machine Learning Impact Care Coordination

Kelsey Waddill: Yes, yes. It also catches you off guard where it's going to happen. LinkedIn has suddenly just become a political platform, and I don't know when that happened, but....

Kyle Murphy: Yeah, I did just see that and I reported a couple of posts and being like, I don't want political stuff on my feed. Yeah, this is professional stuff, so come on, let's keep things professional, LinkedIn.

Kelsey Waddill: Yeah, like Healthcare Strategies | Headlines.

Kyle Murphy: Exactly. And with all seriousness, let's get to the first item.

Kelsey Waddill: Ok.

Kyle Murphy: Alright. So World Health Organization [WHO] has issued new guidelines for the governance of large multimodal models. These are LMMs, these are everything that underpins Gen AI as we know it today. So the World Health Organization was looking at Gen AI in the healthcare space, highlighting over 40 recommendations for governments, technology companies, and healthcare providers. These guidelines aim to ensure the proper use of these language models emphasizing the need for transparent policies to manage risks and achieve improved health outcomes. The guidance covers five key applications of large language models in healthcare, ranging from diagnosis and clinical care to scientific research. However, it also warns of the risks associated with these models such as producing bias or inaccurate outputs and outlines potential consequences like patient harm and adverse outcomes if these risks are not effectively managed. The World Health Organization also advocates for a collaborative approach amongst stakeholders. Governments are urged to take a leading role in regulating AI technologies and providing the necessary infrastructure, while also ensuring that healthcare large language models meet ethical and human rights standards. The guidelines also recommend independent third-party auditing and call for developers to involve all stakeholders early in the development process to enhance transparency and reliability.

Kelsey Waddill: Kyle, considering the interest we both have witnessed firsthand that healthcare companies have in Gen AI, are you concerned that more hasn't been done to regulate its use in healthcare by the US government?

Kelsey Waddill: Yes. That's the short answer. [laughs]

Kyle Murphy: Thank you. Astute. As always.

Kelsey Waddill: I think it's good that WHO is coming out and saying what we are all thinking: that governments need to take action, and more specifically, it needs to be a priority in 2024. The executive order is great, but not enough, and we need actual policy, especially in the US. Technology itself is rapidly evolving, not to mention all the use cases. So it's time for governments to take ownership of it now. And I think it's interesting how WHO highlighted that ownership--getting off the regulatory side--is not just about regulation and setting down the ground rules for the playground, so to speak, but also about building the playground and offering infrastructure for safe exploration of these new technologies. And both are important, and the sooner we get something tangible on either of those or both of them, the better things will be.

Kyle Murphy: It's always the case that innovation outstrips or outpaces regulation, but Gen AI is everywhere and people are using it so much. People have signed on to do it. That to me, it's wild west right now. And that's scary because we know that it can be good, but we also know that it can be manipulated. And we are in a political year, an election year, and I think we all have to appreciate the fact that these are some really sensitive issues that can actually get in the way of the economy, healthcare and stuff like that. So I think this needs to be a top-line priority, if there were any kind of priorities.

Kelsey Waddill: But I also, I'm glad that WHO pointed out [that] healthcare leaders don't have to wait necessarily for the government to take charge. They know what's at stake here better than maybe even the government does. And I think we're getting better little-by-little at the kind of collaboration, stakeholder collaboration that WHO recommended. We've had plenty of practice with value-based care. We should hopefully be ready for that kind of thing by now. One would hope so. Ideally, healthcare leaders can lean into--even with all of the policy level ambiguity--they can lean into those collaborative efforts and employ what they have learned toward AI. But we'll see.

MGH acknowledges boarding and overcrowding issues. Massachusetts General Hospital--or MGH--has a significant capacity problem. According to a recent press release from the hospital, MGH is boarding patients in the emergency department nearly a third more often than in the past. For those who might not be familiar, "patient boarding" occurs when patients are kept in the emergency department after being admitted due to a lack of available inpatient beds. So as a result, the hospital usually faces serious overcrowding issues. Patients face higher rates of ambulance refusals, longer wait times, higher incidents of patient harm. When there's an emergency or natural disaster, it's harder for hospitals to respond efficiently. MGH certainly is meeting the criteria for overcrowding at the moment, particularly in its emergency department. The hospital recorded a 32% increase in patient boarding hours between October 2022 and September, 2023. Patients boarded at the MGH Emergency Department experienced a median boarding timeframe of 14.1 hours in September, 2023 with slightly more than a quarter of admitted patients spending more than 24 hours boarded before finally being placed in an inpatient hospital bed.

MGH leadership has acknowledged this crisis and shared the steps that the hospital is taking to address the situation. The facility will do things like increase its licensed inpatient beds, expand the discharge lounge, leverage hospital-at-home services, improve inpatient throughput and efficiency and enhanced care models. But at the end, they acknowledge that the increased patient boarding is attributed to the COVID-19 pandemic, which placed a significant strain on MGH and hospitals across the nation.

Kyle Murphy: So Kyle, the COVID-19 pandemic continues to haunt hospitals and the rest of the country even four years later. In addition to issues like overcrowding at hospitals, what kinds of pandemic-related impacts do you expect to see in the coming year?

Kyle Murphy: Well, you'll know this one because it might've been, you reported on it, but payers are a little upset that folks are using their health coverage.

Kelsey Waddill: [sarcastic] How dare they?

Kyle Murphy: And their premiums are going towards preventive care services or screenings that were put off during the pandemic.

Kelsey Waddill: [sarcastic] Good lord!

Kyle Murphy: Yeah. So utilization I think is a problem. It's like how can you, oh, I don't want to go down that rabbit hole, but yes. I think one of the things we're going to notice is that I think utilization will uptick, and I don't see how healthcare organizations are going to be able to stomach this or weather this, considering that their workforce is already strained. So I think when it comes to being intelligent, it's really about trying to space things out so patients have access, providers can see patients, and really I think they have to do away with a lot of the administrative burden that prevents providers from actually spending more time with patients. So anything that can be done on the backend to assist these frontline workers is obviously going to be huge. And then back to the original topic, it's just that--EDs are just wild places.

Kelsey Waddill: Yeah.

Kyle Murphy: It's the last place you ever want to show up to.

Kelsey Waddill: Talk about a Wild West.

Kyle Murphy: Yeah, it's the last place you want to be. And I think some folks, healthcare consumers have learned you don't go to the ED for everything. You go to urgent care if it's something that needs to be seen more immediately or you go to a MinuteClinic, something like that for really the quick fix, keep the ED for really high acuity incidents where you need some kind of trauma care. But healthcare literacy is still low, so it's very sad that EDs get swamped and you think given its reputation with MGH, you'd think, oh, it can handle that. But there are a lot more people needing services than there are providers giving them, so--that math, it's not good math.

Kelsey Waddill: Yeah, it's especially striking when you see an organization like MGH struggling with something like this. MGH, which has a name behind it. I mean rural hospitals, we already know were overwhelmed--but MGH?

Kyle Murphy: Yep. And it's wild because in all these places, some folks are funneled to MGH because that's the best hospital around in the area. So it's got that reputation, but at the same time, you can't treat everybody. That's not the way it was designed. And I think we're coming to realize that the healthcare system needs a lot of infrastructure and support and maybe it should be a top-line issue in this year's election, but haven't seen much about it.

Kelsey Waddill: Yeah, I know. Funny how that works.

Kyle Murphy: Alright, let's pivot to some--"pivot" [different emphasis]--let's pivot to some progress being made on physician burnout.

Kelsey Waddill: Yes.

Kyle Murphy: A new KLAS Arch Collaborative survey of more than 53,000 clinicians--I think that's a sizable number--notes a slight decline in clinician burnout since 2022. Thanks to burnout mitigation efforts by healthcare organizations--kudos to those really making an effort. Despite this, burnout levels are still above pre-pandemic rates. Key findings include: staffing shortages are the primary factor contributing to clinician burnout, followed by inefficiencies and a lack of alignment with leadership values. The EHR--we all know about the EHR--is less frequently cited as a contributed burnout. Proper EHR utilization can actually mitigate burnout by improving efficiency. Addressing burnout is in its early stages. It involves increasing EHR efficiency through training and IT personalization. For advanced burnout stages, it's crucial to realign leadership values with clinicians and foster and inclusive organizational culture--I think they call it empathy? And the top strategies to alleviate burnout are improving staffing--shocker--ensuring better-aligned leadership. And, depending on the profession, enhancing EHR efficiency or offering better pay--I think that "better pay" one probably should have been higher up. People are willing to do a lot of things if you pay them appropriately. If increasing staff is not feasible--it's not--optimizing EHR training and workflows as well as addressing pay disparities are recommended. So Kelsey, I think you would agree with me that healthcare has a culture problem?

Kelsey Waddill: Yes,

Kyle Murphy: For sure. Are healthcare leaders doing enough to listen to the concerns of providers and isn't taking care of providers crucial to ensuring patients ultimately benefit from the best care possible?

Kelsey Waddill: Yeah. It was funny, I mentioned this on the 2024 predictions episode, but whatever happened to the fourth part of the quadruple aim, which was the "provider experience"?

Kyle Murphy: Oh, we had to jump past it. We had to get to equity, we had to expand the paradigm.

Kelsey Waddill: Well, which is also really important.

Kyle Murphy: Yes.

Kelsey Waddill: But I mean, provider experience is essential to the patient experience. You're right. I think a lot of this--and I think the survey demonstrates this--a lot of it ties to leadership and are leaders really listening to the people who they're employing. In any business situation, that's an important key strategy, should be. But I think it's also interesting what they emphasized about the EHRs role, and I think it underscores the fact that we've learned a lot about how preventive care can help patients. And I feel like we now need to apply that to providers a bit too. We need to start earlier on. There's some underlying issues from the very beginning. So let's start out with the tool that every brand new, fresh-out-of-med-school-provider uses, which is the EHR, and let's make sure that that experience isn't going to become a burden for them. And then hopefully we'll be able to figure out the downstream stuff as well.

Kyle Murphy: Because you certainly can't, can't replace a doctor with AI, right? You just can't.

Kelsey Waddill: No.

Kyle Murphy: So these people are essential and technology needs to be suited to making them actually have satisfaction, actually be able to complete their job--not just to get the bare basics, the bare minimum done, but to actually enjoy the practice of medicine, to actually have those interactions where they're doing the things they're trained to do, which is to help people with their health and to hopefully improve their health status so people can live meaningful lives. And providers are people too. The time has come. I just wish it didn't take a pandemic to get there. You know what I'm saying?

Kelsey Waddill: For sure. Yeah. And speaking of providers and of technology and automation....

Provider groups are applauding CMS for its recently finalized patient data sharing and prior authorization policy updates.

Kyle Murphy: Woohoo!

Kelsey Waddill: Woo!

The CMS Interoperability and Prior Authorization Final Rule requires Medicare Advantage, Medicaid, and Children's Health Insurance Program plans to respond to prior authorization requests within 72 hours for urgent requests and seven days for standard requests. These changes are going to go into play in 2026.

Also, payers have to clearly lay out the reasoning behind prior authorization denials. That's a big one.

And lastly, the rule requires the implementation of HL7 FHIR--

Kyle Murphy: [whispered] Fire!

Kelsey Waddill: --FHIR Prior Authorization API to improve efficiency and electronic prior authorization. Uptakes major provider organizations, including the Medical Group Management Association (MGMA) and the American Medical Association (AMA) viewed the rule as a crucial step in reducing prior authorization burdens. They lauded the increased transparency provisions that shed light on the rationale behind denials, and that publicize aggregated metrics on prior authorizations over the course of the year.

They also supported the use of electronic prior authorization processes and highlighted the benefits of automation. Now, there was still a bit of pushback from some providers who did find room for improvement. Some organizations, such as American Medical Group Association (AMGA), they pointed out that commercial plans remain exempt from this requirement, and they called on CMS to bring those payers in. They also advocated for shorter decision timelines. And then the American College of Rheumatology expressed concern that the electronic prior authorization requirements would actually add to provider's workload, specifically for providers who are participating in the Merit-based Incentive Payment System (MIPS) program.

However, all in all, among those major provider groups, the rule is generally seen as a step in the right direction toward reducing physician burnout as we just talked about. And also for improving patient's access to care.

Kyle, prior authorizations have been a major pain point between providers and payers for such a long time. What do you think about these steps to rectify this old wound, this old feud?

Kyle Murphy: I would say it is a step in the right direction, and I feel like it is a really good starting point now. I think what hasn't really been detailed fully is what is the penalty for this? And I imagine there'll be a reduction in reimbursement rates, so a penalty kind of understanding that's the way MIPS, the quality payment program, has worked. I think this is fantastic. And one of the reasons I would say that is: Medicare Advantage is one of the biggest portion of healthcare spending in the United States, and more and more Medicare-eligible folks are opting for these commercially-run government plans. So I would think it makes perfect sense that these rules start here.

Plus, CMS only has oversight over a certain portion of the healthcare population. They can't go around and, without getting approval, expand its authority. So you got to start with things you can control. And these government programs are hugely important and they're huge cost centers and a lot of complaints have been made about the prior auth procedure. And there have been questions about AI systems being used to deny claims. And I think it's a stat like one in five Medicare Advantage claims is rejected erroneously. So let's get that number right and let's assure that Medicare patients, Medicaid chip patients, that these folks receive care in a timely manner because we know that that time to decision is really starting the process of healing or recovery, and we can't keep on kicking things down the road.

So it's a win. It's a win. And when rules like this start making a certain portion of the industry upset, it's usually a good thing because there needs to be reform. And industry experts have been calling for reform for quite some time.

Kelsey Waddill: Yes.

Kyle Murphy: So it's good to see it happen. 2026 seems like pretty far off, but I understand you have to build in for transition, but hopefully as time goes on, you'll see a tightening up of some of these rules.

Kelsey Waddill: Yeah, I was going to say 2026 is a little farther out than I think that would be the thing I would be complaining about. But Medicare and Medicaid have often been the testing ground for a lot of things that end up taking hold in the industry more officially. So hopefully that's the case here.

Kyle Murphy: Well, ending on a high note, which is good.

Kelsey Waddill: Yeah, look at us breaking trends. 2024 is a new year.

Kyle Murphy: Yeah, new me. New you. Well, thank you everybody for joining us today. It's been Healthcare Strategies | Headlines, and as always, we appreciate your time today. Take care.