By Deanne Kasim, Founding Partner, Santesys Solutions
Twitter: @DKASIM
With the increase in specialty drugs, innovative diagnostic testing, and precision medicine, it is expected that the use of the Prior Authorization (PA) will only increase with health insurance companies. Of course I have heard from many re: the (theoretical) fact that as the use of value-based provider reimbursement matures, there will be less and less need for a PA process. I absolutely disagree. The increasing development and costs of specialty drugs alone (up to $100,000/year to treat ONE Hepatitis C patient – hello!) will ensure the use of PA will not decrease.
The PA process is expensive and largely a labor intensive effort. One executive from a large IPA in Northern Virginia told me last year that each PA costs his plan over $40 to process and obtain (!). Other disappointing facts:
- An AMA survey (2014) of 2,400 physicians found that many were spending up to 20 hours per week on PA requests.
- The AMA found that 69 percent of physicians report waiting at least several days to receive authorization from a plan for patient medications, and 10 percent wait more than a week. Many patients are unable to pay for medications while they wait so many choose to reduce or stop their medications, often with adverse consequences.
- Up to 90 percent of PA requests require a fax or phone call.
I am still caught in a PA “black hole” involving a PA for a specialty drug, a specialist practice affiliated with and located on the campus of a major academic medical center, a PBM (that owns a large drug store chain), and a large, regional health plan. The PA for my treatment was (allegedly) submitted to the PBM on February 5, and this is not a story of an IT fail. Rather it is a sad story of inefficient processes in the provider office, confusion by the PBM, and lack of timely communication among all stakeholders involved, including the patient (me).
Key problem areas I encountered:
- Apparently only one admin was responsible for processing a PA and did not have the proper information (i.e., the PA should go to the health plan first and NOT the PBM). When this person went out on medical leave apparently no one else in the practice knew what to do.
- The doctor did not understand the PA criteria either, and actually gave me a paper script to take to the affiliated drug store and get filled (!). This makes no sense whatsoever – patients are not allowed to administer this drug themselves for good reason, and therefore are not allowed to have possession. (PS – drug stores do not stock most injectables).
- The drug store told me they would submit the script to PBM and then PBM would send the drug to store for me to pick up (continuation of the lunacy of #2). This couldn’t be more false.
- Two weeks later – and 4 weeks in – I contact PBM regarding status. PBM tried to process as a pharmacy claim when in fact this is a medical benefit claim. And no one has submitted any PA information to health plan yet…
I am 74 days into the PA process with (I think?) an end in sight. But I work in the industry – how many patients would have either completely lost their sanity and/or given up?
But wait! Wasn’t the electronic prior authorization (ePA) supposed to make this process easier? (In July of 2013, after over 15 years in development, stakeholders approved the National Council for Prescription Drug Programs (NCPDP) ePA transactions within the SCRIPT e-prescribing standard).
Ideally an effective ePA solution does the following:
- Leverages existing eligibility data and PBM connectivity through EHR integration,
- Use existing e-prescribing workflows,
- Auto-populates key fields, such as patient data, health plan information and medication history from your EHR,
- Communicates with PBMs in real time, and
- Automatically routes pre-approved e-prescriptions to the pharmacy.
Sounds like nirvana to me…I hope I get to experience this one day soon. In the interim, the point of this narrative is to (once again) emphasize that all the newest IT solutions in the world cannot solve a problem resulting from a bad (or disjointed) process.
Lessons to be learned from my story:
- Do not undervalue practice managers – doctors will get what they pay for, which often is nothing because they don’t have one, or they don’t take the time to adequately train the staff.
- Practice staff need to have easy access to PA information, particularly for the growing list of specialty drugs. Health plans need to make this easier for both consumers AND contracted providers to find online. (I know where to look and could honestly NOT find this information in my health plan portal or website).
- IT companies on the payer AND provider side need to understand the tremendous value from integrating ePA capabilities into workflow. (Can we please get away from phone/fax?!)
- Take the time to educate consumers on exactly the procedures and specialty drugs that will require a PA and update this information frequently as the list changes. Be clear on what is a medical PA and what is a PA. It’s transparency and clarity of information that gets consumers engaged.
I am not alone in my frustration and misery…one provider’s point of view
This article was originally published on Santesys Solutions and is republished here with permission.