本文由小咖机器人翻译整理

期刊来源：BMJ

原文链接：https://doi.org/10.1136/bmj-2023-077797

摘要内容如下：

客观

衡量和比较美国保险公司事先授权（PA）政策的范围，即保险公司评估计划医疗护理的必要性的过程，并量化保险公司、医师专业和临床服务类别之间的PA差异。

设计

横截面分析。

设置

五家保险公司的PA保单，服务于2021年美国私人管理的医疗保险优势计划（Medicare Advantage）所覆盖的大多数受益人，适用于医疗保险B部分中观察到的使用模式。

参与者

30540086传统医疗保险B部分的受益人。

主要结果指标

根据Medicare Advantage保险公司规则，政府管理的传统Medicare Part B支出和使用比例需要PA。

结果

保险公司为14130项临床服务中的944至2971项（中位数1899；加权平均数1429）要求PA，占B部分支出的17%至33%（中位数28%；加权平均值为23%）和9%至41%的Part B利用率（中位数为22%；加权平均值18%）。支出的40%（570亿美元；450亿英镑；530亿欧元）和48%的服务利用率将需要至少一家保险公司的PA；12%的支出和6%的利用率将需要所有保险公司的PA。93%的B部分药物支出，或74%的药物使用，需要至少一家Medicare Advantage保险公司的PA。对于所有Medicare Advantage保险公司而言，血液学和肿瘤学药物在PA支出中所占比例最大（范围27-34%；中位数为33%；加权平均值30%）。各专业的PA率差异很大。

结论

美国私营保险公司的PA保单差异很大。尽管共识有限，但所有保险公司都广泛要求PA，特别是医生管理的药物。这些调查结果表明，政府管理的医疗保险和私人管理的医疗保险之间的覆盖政策存在实质性差异。研究结果可以为正在进行的努力提供信息，以更有效地将PA集中在低价值服务上，并减少临床医生和患者的管理负担。

英文原文如下：

Abstracts

OBJECTIVE  To measure and compare the scope of US insurers' policies for prior authorization (PA), a process by which insurers assess the necessity of planned medical care, and to quantify differences in PA across insurers, physician specialties, and clinical service categories.

DESIGN  Cross sectional analysis.

SETTING  PA policies for five insurers serving most of the beneficiaries covered by privately administered Medicare Advantage in the US, 2021, as applied to utilization patterns observed in Medicare Part B.

PARTICIPANTS  30 540 086 beneficiaries in traditional Medicare Part B.

MAIN OUTCOME MEASURES  Proportions of government administered traditional Medicare Part B spending and utilization that would have required PA according to Medicare Advantage insurer rules.

RESULTS  The insurers required PA for 944 to 2971 of the 14 130 clinical services (median 1899; weighted mean 1429) constituting 17% to 33% of Part B spending (median 28%; weighted mean 23%) and 9% to 41% of Part B utilization (median 22%; weighted mean 18%). 40% of spending ($57bn; £45bn; €53bn) and 48% of service utilization would have required PA by at least one insurer; 12% of spending and 6% of utilization would have required PA by all insurers. 93% of Part B medication spending, or 74% of medication use, would have required PA by at least one Medicare Advantage insurer. For all Medicare Advantage insurers, hematology and oncology drugs represented the largest proportion of PA spending (range 27-34%; median 33%; weighted mean 30%). PA rates varied widely across specialties.

CONCLUSION  PA policies varied substantially across private insurers in the US. Despite limited consensus, all insurers required PA extensively, particularly for physician administered medications. These findings indicate substantial differences in coverage policies between government administered and privately administered Medicare. The results may inform ongoing efforts to focus PA more effectively on low value services and reduce administrative burdens for clinicians and patients.

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