Impact of Electronic Prior Authorization on Care Delivery

San Diego—For pharmacists, prior authorization presents a number of challenges that can result in patients having to wait to fill medications because there is often no warning that authorization is required. Occasionally, back and forth between physician and pharmacist occurs, which creates both a cost and time burden of getting prescriptions filled.

Implementation of electronic prior authorization can help alert physicians and patients before a prescription is sent to the pharmacy and thereby expedite authorization so that it is completed prior to sending the prescription to the pharmacist.

At a session at AMCP, experts discussed the current status of electronic prior authorization, as well as an overview of outcomes of a 2-year electronic prior authorization pilot program.

Need for Electronic Prior Authorization and New Standard

Putting in context the need for improvements in prior authorization, Ajit A. Dhavle, PharmD, MBA, vice president, Clinical Quality, Surescripts, opened the session highlighting the cost and time burden of prior authorization on prescribers, pharmacy benefit managers (PBMs), and pharmacies.

In addition to consuming time for pharmacists, prior authorization incurs a cost of $11,440.00 per pharmacist every year. “Pharmacists spend an average of 4 hours a week on prior authorizations, representing a significant amount of time that could otherwise be spent providing care to patients,” said Dr. Dhavle.

Overall, he said that streamlining prior authorization is a top priority for providers with data showing that 91% are frustrated with prior authorization. To help do this, a new standard for electronic prior authorization was officially approved in July 2013 as a major advancement for e-prescribing. The National Council for Prescription Drug Programs (NCPDP) standards enables options for electronic prior authorization workflow. At the prescriber level, it includes prospective workflow initiated by the prescriber level before sending an e-prescription to pharmacy. In other words, the physician identifies drugs that require prior authorization before a prescription is sent. The standard also includes retrospective workflow initiated at pharmacy after prescriptions are sent and rejected by pharmacy benefit management (PBM).

The new best practice that emerged from this new standard includes leveraging eligibility and formulary data to notify providers of the need for medication prior authorization before e-prescribing, and sending specific prior authorization questions to the electronic health record based on the patient, plan, and medication (without the need for forms). In addition, before sending the e-prescription, prior authorization review is completed in real-time communications with PBM and preapproved e-prescriptions are routed to pharmacy with no block on prior authorization.

“By implementing an electronic prior authorization solution, physicians and their staff can connect directly with their patients’ health plans to complete the prior authorization process without enduring the pain of using outdated and slow phone, fax, and portal systems,” said Dr. Dhavle.

Case Study: Implementation of an Electronic Prior Authorization Program

Gulzar Virk, MBA, product manager, Physician Connectivity, CVS Health, illustrated the implementation of an electronic prior authorization pilot program at CVS/Caremark.

Launched in May 2012, the pilot program included using electronic prior authorization for a number of transactions. The program supported a variety of clients including commercial health plans, Medicare, Medicaid, and specialty.

The pilot program found that about 11% of the total prior authorizations completed through Caremark were done via electronic prior authorization at the end of 2014. About 17,000 unique national provider identifiers (NPIs) were requesting electronic prior authorization, and the top drug classes in which electronic prior authorization was used were sedative hypnotics, amphetamine, proton pump inhibitors, testosterone/Cialis, and methylphenidates.

Overall, prescribers reported a positive experience in the pilot program with 85% finding that electronic prior authorization was supportive of the process and that requesting criteria was simple. Another 80% found submitting prior authorization criteria to be an easy process.

Lessons learned from the pilot project, according to Dr. Virk, included a faster turnaround time using electronic prior authorization and that duplicate scenarios were detected at the front end of the process. The portal, however, was not seen as a long-term solution. Rather, electronic prior authorization was seen as much better as part of the e-prescribing workflow, said Dr. Virk. Overall, more experience is needed to understand how electronic prior authorization will work in practice and how it will affect pharmacy workflow.

Going forward, Dr. Virk encouraged participants to accelerate the adoption of electronic prior authorization by embracing technology, considering electronic prior authorization when building future criteria, bringing electronic prior authorization into discussion when talking with federal and state level regulatory bodies, and assisting their organizations to put the process in place for electronic prior authorization.—Mary Beth Nierengarten