Article written by Nicole Lovullo, PharmD, RPh, Group Copy Supervisor for Maxcess Managed Markets


Background:

Although it is an effective utilization management strategy, patients, pharmacists, and providers find the prior authorization (PA) process to be extremely burdensome and even detrimental to patient care. Many patients believe their prescription constitutes their prescriber’s authorization and may not understand why there is a delay in obtaining their prescription. Behind the scenes, already overloaded pharmacists are acting as the middlemen trying to link provider and payer to expedite the PA process by asking plans to fax PA forms to providers and contacting already overburdened providers’ offices to complete and submit the forms. An added layer of complication exists when these forms require documentation of previous therapy that may not have been tried or tests that might not have been done.

Analysis:

In a survey by the American Medical Association (AMA) of 1000 practicing physicians (40% PCPs; 60% specialists), almost 85% reported high or extremely high burden associated with PAs for physicians and staff in their practice and the vast majority reported this burden has worsened over the past 5 years.1 Even more concerning is the 92% of respondents who said that the PA process delays care, and that delay is at least 1 business day in almost 65% of cases. It has become such a burden that the AMA has ongoing advocacy efforts and resources to reduce PA-related workload.

Implications:

Unfortunately, a strategy aimed to drive utilization of preferred formulary products may backfire when patients wind up abandoning treatment altogether. Delays in care and prescription abandonment may lead to negative clinical outcomes and increases in overall healthcare costs, not to mention dissatisfaction from all stakeholders. For these reasons, it is in the payer’s best interest to make the PA process as clear and easily navigated as possible.

Conclusions:

PAs are not going away any time soon, so how can we best serve our patients while navigating these hurdles? There are a number of actions that can expedite the PA process.  Implementing clinical pathways can help to ensure the appropriate information is collected and available when needed.2 Bridging therapy with product samples or alternative treatment could help patients get started while a claim is under review. Communication with patients about the importance of therapy may encourage them to come back to the pharmacy to get their prescription once approved.

Next Steps:

  • Encourage office staff to conduct benefits verifications prior to prescribing to proactively identify potential access barriers or to focus on more accessible products
  • Implement clinical pathways to help ensure required therapies and tests are completed for faster review and processing of PAs
  • Bridge therapy with samples or alternative therapies to avoid delay in treatment
  • Educate patients on the PA process and the importance of starting and staying on therapy
  • Propose formulary product selections at claim submission reject screens so pharmacists can make recommendations for alternate therapy that will be covered without hurdles
  • Develop integrated data systems where pharmacists can access patient records and complete PAs to expedite the provider-payer PA process

 

Reference(s):

  1. American Medical Association. 2017 AMA prior authorization physician survey. https://www.ama-assn.org/sites/default/files/media-browser/public/arc/prior-auth-2017.pdf. Accessed March 23, 2018.
  2. Lokay K. Clinical pathways can prevent prior authorization delays. http://www.ajmc.com/conferences/pcoc-2017/kathleen-lokay-clinical-pathways-can-prevent-prior-authorization-delays. Published December 24, 2017. Accessed March 21, 2018.