Development of Electronic Prior Authorization Has Reached an Inflection Point

San Francisco—“With the possibility of radical changes in the way pharmacy benefits are administered and delivered, the development of electronic prior authorization (ePA) has reached an inflection point, and the industry needs to work efficiently and quickly toward efficiency and standardization,” a leading ePA administrator and developer said.

In a Contemporary Issues session at the AMCP meeting titled Electronic Prior Authorization Initiatives at the Point of Service: Moving the Industry Forward, representatives of several healthcare providers discussed the methods they use for ePA. Anthony Schueth, MS, CEO and managing partner of Point-of-Care Partners, LLC, provided a history and overview of ePA today.

The prior authorization (PA) process has traditionally caused delays in the process by adding steps for prescribers, pharmacies, and insurers alike. These delays and unnecessary holdups often adversely affect patients (creating delays that cause patients to receive drugs later than optimal for treatment). For pharmaceutical companies as well, delayed and abandoned prescriptions and unnecessary administrative costs detract from the bottom line.

Use of ePA allows the provider to electronically request a PA question set, return the answers to the payer, and receive a real-time response. It greatly facilitates the prior authorization process. “Although there is now automation in the PA process as we know it, it is in effect a mere duplication of the paper process from years ago,” Mr. Schueth said. He suggested that ePA be integrated into a web portal for prescribers and their staff, and that the ePA process could be further refined to improve clinical workflow.

“With paper forms still being used in some parts of the PA process, and the various stakeholders in the process still not synchronized, there is a need for a better, universal process. Federal government initiatives have placed the industry in good stead, but now the industry itself must take the initiative to establish universal standards for ePA,” said Mr. Schueth. To that end, the National Council for Prescription Drug Programs (NCPDP) launched an industry-wide task force in 2011 to address these goals.

Amid concerns about formulary accuracy, the task force is currently working on an XML version of a NCPDP ePA Standard and what is known as the Real-Time Benefit Check. CVS Caremark, Humana, and RelayHealth are working to begin implementation of the findings and recommendations of the task force.

Marc Nyarko, MPH, director of pharmacy operations, Humana Clinical Pharmacy Review, Humana, continued the presentation by noting that Humana’s goals are to standardize drug utilization management to ensure patient safety, efficacy, and effectiveness of medication, ensure that the correct medication is administered at the right time using evidence-based medicine, and ensure appropriate access to care. Other goals are to reduce labor requirements, make quality decisions based on the member’s benefit, and provide faster turnaround times.

Bruce Wilkinson, MBA, clinical advisor at CVS Caremark, said that CVS Caremark is working hard to encourage the use of e-prescribing, including the use of a computer or handheld device to electronically route each prescription to a patient’s choice of pharmacy, electronically access that patient’s prescription benefit, and, with the patient’s consent, electronically access that patient’s prescription history.

According to Roger Pinsonneault, RPh, senior director of project management at RelayHealth, a very significant challenge for the industry is the high number of prior authorization rejections annually. He said there are 120 million PA rejections per year, and the number is growing. Of these denied prescriptions, a high percentage are never filled by the patient. Specialty drugs, which require a PA 34% of the time, are 5 times more likely to require a PA than nonspecialty drugs. In addition, PAs and high patient out-of-pocket costs are typically cited as the 2 most significant barriers to patients obtaining biologics.