Prior auths exacerbate the opioid crisis but tech can help

The opioid epidemic continues to shatter lives and devastate communities, with more than 80,000 deaths in 2023 attributed to overdoses of opioids, including prescription drugs. While many of these tragic deaths are tied to recreational drug use, many are also the result of misuse of prescription medications that were originally intended to manage legitimate illness or injuries. 

The American Medical Association (AMA) estimates that up to 19% of people who take prescription pain medications develop an addition to them. And when people can’t get access to these prescriptions, they may switch to heroin to satisfy their needs. In fact, about 45% of people who use heroin started off with an addition to prescription opioids, the AMA adds, before progressing to harder substances. 

It’s a pipeline that has frustrated pain management physicians for years. Opioids can be a valuable component of the treatment toolkit, but the acknowledged risks of addiction mean physicians only want to employ these drugs sparingly, and for limited time periods, as a bridge between the onset of pain and the delivery of (hopefully) curative treatment. 

But sometimes, red tape gets in the way. When pain management physicians cannot prior authorizations (PAs) for imaging tests and other services that can open the way to meaningful treatment, patients are forced to rely on opioids for interim pain relief much longer than is desirable. This dramatically raises the risks of addiction, and can send patients down a dangerous spiral. 

Much has been written about how time consuming, excessive, and overly restrictive prior authorizations contribute to delays in care, with 94% of physicians saying they have experienced prior authorization-related barriers in access to necessary care, often resulting in lengthy delays that contribute to adverse outcomes. In the world of pain management, it’s not hard to connect the dots between these prior authorization-induced care delays, the resulting overreliance on opioids, and the heightened risks of addiction. 

At South Texas Spinal Clinic (STSC), which has been serving the San Antonio region for 37 years, breaking this cycle to safeguard the community is a top priority.  The growing clinic has made a concerted effort to examine its prior authorization processes and deploy technology to reduce the time between assessment and treatment so patients can get the right care in a timely manner.  

Addressing the link between prior authorizations and care delays in a high-risk environment

At the beginning of its prior authorization improvement journey, STSC was experiencing a relatively high volume of patients who were seeing delays of six to eight weeks on some pain management procedures, partially because of the challenges of securing PAs from their health plans. 

“As a result, they often needed narcotic pain medications to get them through with some daily function intact, which is not the ideal solution,” explained Angela Szymblowski, Director of Clinical Operations of the clinic’s Stone Oak division. “Our physicians don’t just want to medicate; they want to provide treatments that resolve the root causes of pain.” 

Prior authorizations often stand in the way, especially because the requirements can vary across health plans. For providers, it can be hard to keep track of what each plan requires – and it can be equally difficult to ensure consistency in submissions when the process is being completed manually.  

“Even your best employees will have different interpretations of what the payer is asking for, and that can cause major delays if they’re not quite correct,” she said. “The more you can gain transparency into requirements and standardize how you respond to requests, the less likely you’ll get a denial due to missing information, incorrect data, or some other paperwork issue.” 

Leveraging technology to streamline prior authorization submissions

STSC decided to partner with athenahealth to implement an AI-enabled platform that could shorten the timeframe for prior authorizations to be approved.   

“The tool provides a standardized checklist based on built-in criteria so that we’re consistently offering the payer everything they’re asking for the first time around,” said Szymblowski. “It helps us – and the patient – avoid the struggle of being unable to get an MRI or other test before they can even get their treatment.  With the platform, we’re often able to secure prior authorizations to get an MRI done same-day. We get that report within 24 hours, and we’re able to move to the next appropriate step of treatment in just a few days based on those results.” 

Since implementation, the average wait time for procedures has plummeted from between six to eight weeks to just around two weeks.   

“It’s been a huge benefit across multiple dimensions,” she commended. “Patients are getting the right relief much quicker than before, which is the main goal. It also helps us, as an organization, to reduce the manual investment required to process requests. We would need an additional six full-time employees to do what our AI platform can do for us, so we’re very pleased not to have to bring on those extra people. Lastly, it strengthens our reputation in the community as a high-quality, patient-centered care provider, which helps us build sustainability.”  

Fueling growth while building trust across the community

About 16 million US adults experience chronic back pain, and the numbers are rising as the population gets older. The need for speedy and effective pain management is only going to increase – as will the risks of addiction if pain management isn’t handled by reputable, trustworthy clinicians who understand how to prevent patients from falling through the cracks. 

At STSC, the focus on reducing prior authorization-induced barriers to care has helped reinforce their position as a clinic that always puts its patients first, said Szymblowski.   

“Since implementing our technology, the volume of referrals has increased significantly, mostly by word of mouth, since we’re so fast at getting patients the care they need,” she said. “Primary care providers in the community will call us up and ask if they can send their patients to us because they know we’ll get it done fast – and they know that our pain physicians are not heavy prescribers of Schedule II drugs, which is important to everyone in the community.”   

“No PCP wants to send their patients to a pain specialist who’s just going to medicate them and send them away. It’s not in their ethos as medical practitioners, and it’s not in ours, either.” 

She added at STSC has become the preferred pain management specialist for one of the biggest payer-provider networks in the state because of the speed and care with which the clinic’s specialists treat their patients. 

“Because of the trust we’ve built with them based on proven results, they have given us the authority not to delay care for their patients if the patient meets the right clinical criteria,” she said. “They understand the broader implications of unintended barriers to care, and we’re very proud to be working with them to streamline access for people in need.” 

Because of their successes, STSC has recently onboarded more physicians and is in the process of opening an additional location. 

“This is one of those things that’s good for everybody involved,” Szymblowski said. “It’s good for patients to get the right care at the right time and reduce the chances of unintended negative outcomes.  It’s good for our clinic to be able to provide that care quickly and correctly, and it’s good for health plans to avoid the costs of preventable utilization by connecting patients with care faster.”    

“Time is of the essence in pain management, so whenever there’s an opportunity to become more efficient and serve the population better, especially through technology, we need to take it.”   

Jennifer Bresnick is a journalist and freelance content creator with a decade of experience in the health IT industry.  Her work has focused on leveraging innovative technology tools to create value, improve health equity, and achieve the promises of the learning health system.  She can be reached at jennifer@inklesscreative.com.