December 1, 2014
The following might sound like a joke but the scenario isn’t funny: A patient walks into a pharmacy to pick up her prescription, and heads to the counter to get her prescription filled only to learn that the drug requires prior authorization from her insurance company.
The patient, frustrated, calls back the physician’s office to find out what’s going on. The patient’s treatment is now delayed. The physician’s office then has to manually process the patient’s prior authorization or choose an alternative treatment that will be covered. Even if the prior authorization process goes smoothly, it may take two days for the patient to receive their script.
The Current Prior Authorization Model
Altogether, the whole process impacts many parties including, most closely, the pharmacy staff and the provider. Here’s how the current prior authorization process impacts stakeholders:
|Patients||Delays in treatment, low satisfaction, limited knowledge of process|
|Pharmacy||High call volumes, high costs of restocking meds|
|Providers||Time spent processing prior authorization|
|TPAs (PBMs) and Health Plans||Money spent to process/review each prior authorization transaction|
|Pharma||Increased prescription abandonment, extensive physician and patient administrative assistance|
The manual prior authorization process places the burden primarily on providers and pharmacy staff to initiate and manage the medical review on behalf of the patient. The process requires that healthcare providers and pharmacy staff locate the acceptable forms based on the patient’s eligibility, complete the forms based on the data in their e-prescribing/Electronic Medical Record (EMR)/Health Information System (HIS) solution, and submit the forms to the corresponding payer or Pharmacy Benefit Manager (PBM), typically via fax. In fact, the process is time-consuming and frustrating for many prescribers:
- Physicians spend up to $10,0001 per year manually processing prior authorizations
- 91 percent2 of physicians are frustrated with prior authorization
- Two-thirds of patients wait two days3 to receive their script
- Processing prior authorizations takes five to eight hours1 per week, per physician; over 20 hours3 of clinical and clerical time4
Engineering Healthcare Progress
Having authorization before the patient leaves the physicians office, or at least before the patient arrives at the pharmacy, is the first step in supporting medication adherence. The current procress does not ensure the patient will receive approval on their medications, and can break the first “chain” in patient medication adherence.
As an improvement to the manual prior authorization process, payers and PBMs have created portal solutions, which allow healthcare providers and pharmacy staff to transmit prior authorizations digitally. These portals act as form repositories and as a means for submitting and tracking prior authorizations. However, this process stops short of reducing the administrative burden on healthcare providers and pharmacy staff.
Electronic Prior Authorization Legislation
At the same time that the healthcare technology industry is making a move toward ePA, states are beginning to recognize its benefits. Below is a map of the states that have ePA mandates:
- Eight states have mandates for ePA
- Numerous states have drafted laws, several are planning ePA mandates
The Case for ePA
The case for ePA is evident. ePA is one of the most significant areas of progress within the healthcare industry, as it addresses one of the most stressful, time consuming and inefficient processes that providers face. Overall, based on commentary and data about the manual prior authorization process, the technology is a welcome improvement upon the current process. And that’s no joke.