Optimization Reviews are a tool used by Medicare, businesses, and private insurers to improve healthcare quality, safety and affordability.

In the medical world, these reviews are often labeled ‘prior authorizations’ by hospital systems and providers.

Hospitals and doctors bemoan Optimization Reviews on the grounds they delay care for patients. Legislation has even been put forward at the federal level to end them for Medicare.

Everyone can agree that excessive care delays are unacceptable. Eliminating Optimization Reviews, however, would have major negative impacts on the healthcare consumer.

For starters, the healthcare system is largely fragmented. Patients see several different doctors and multiple practice locations. Hospitals, pharmacies, and lab work are often separate.

Often, one may not know what the other has prescribed, what tests have been run, or what treatments have been tried.

Performing these reviews ensures care is safe and cost effective.  

For example, one study of the Veterans Administration found that more than 10 percent of their Optimization Reviews uncovered and prevented potential adverse drug events and medication errors that could have harmed veteran patients.

Those are saved lives.

Optimization Reviews also prevent fraud, waste, and abuse.

A study in the Journal of the American Medical Association estimates that fraud, waste, and abuse cost $760 billion to $935 billion. That represents almost 25 percent of total health care spending.

Waste is so high that the Government Accountability Office (GAO) even recommends Medicare expand their use of Optimization Reviews to control unnecessary spending.

These reviews can help prevent unnecessary tests, duplicate imaging and redundant lab work, for instance.  

How costly would it be to get rid these reviews?

The Congressional Budget Office recently found that eliminating Optimization Reviews for Medicare Advantage Plans alone would cost more than $16 billion over 10 years.  

Finally, Optimization Reviews help prevent the ‘pay-for-play’ dynamics that exists in the medical industry.

According to the Centers for Medicare and Medicaid Services, in 2019, physicians received 615,000 payments from drug manufacturers and med tech companies worth over $3.5 billion.

These payments are directly associated with increased prescribing of the paying company's drug and increased prescribing costs.

Without Optimization Reviews to ensure appropriateness, ‘pay-for-play’ could run amok, driving costs for consumers even higher.

Payers – be it the government, self-funded businesses, or private insurers – must ensure Optimization Reviews are done in a timely manner so that care is not excessively or inappropriately delayed.

But until care is better coordinated, waste and fraud are under control, and pay-for-play isn’t so prevalent in the healthcare industry, these reviews are an essential tool for patient safety and affordability.

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