Health Fellow Spotlight: Lucy He, Aspen Tech Policy Hub

In a 2020 American Medical Association survey, 94% of physicians reported that “Prior Authorization” (PA), a wide-reaching healthcare insurance procedure, caused delays in care to their patients, and 21% of physicians noted that PAs led to hospitalizations. My big idea is to use software, known as real-time benefit tools (RTBTs), to decrease the harm caused to patients by the PA process.

Prior authorization (PA) refers to the process of getting an insurer’s approval before a physician provides a treatment. Today, the PA process often harms patients by either delaying care or by denying payment for care altogether. These harms are wide-reaching because PAs can apply to any type of patient care, including lab tests, medical procedures and drugs.

Because underserved and minority patients disproportionately suffer from chronic conditions (e.g. cardiovascular disease) that require PAs for treatments, delays in PAs reinforce structural inequities to care access among those patients.

Real-time benefit tools are a software product used by healthcare providers when they are choosing a drug for a patient. Centers for Medicare and Medicaid Services (CMS) describes their purpose as: to “make beneficiary-specific drug coverage and cost information visible to prescribers who want to consider that information at the point-of-prescribing.” 

RTBTs have the potential to reduce the harmful effects of PAs for drugs by speeding up the PA process. They do this both by providing real-time PA requirement information to physicians and by enabling patients to avoid PAs altogether. A study done by Johns Hopkins has shown evidence for this promise.

My colleague, Christine Keung, and I are continuing efforts to increase chances of adoption, which will depend on different factors that are still unfolding. Timing is one key factor. For example, Senate Bill 4620A is an active bill in New York State that influences RTBTs; if this bill is passed, there is greater urgency for adopting our regulation as well. We expect updates on SB4620A in the summer of 2022.

Our regulation is focused on improving RTBTs, but we’ve seen similar regulations for other types of healthcare software tools. In those cases, we’ve seen states closely follow precedents set by other “early adopter” states. This happened with electronic prior authorization solutions, for example. We hope our regulation can create similar momentum for RTBTs.

Gathering public support is a key part of our advocacy plan for our regulation. We are collecting signatures for a letter of support addressed to the New York State Department of Health, and we would love the participation of patients and providers. Details about the letter and how to sign the letter can be found at tinyurl.com/BetterPA.

Personal experiences have shown me how different qualities of care impact individuals and families. This sent me on a constant search for high impact technology levers for improving patient care.

Then, working in health tech at Flatiron Health, I was able to learn about the potential for healthcare policy from Flatiron’s many policy experts. I was inspired by these individuals’ passions and skills in working across the three disciplines of tech, health and policy. For me, this is when things “clicked” — and when policy was added to the tech and healthcare toolkit I hope to use to serve patients.