Electronic prior authorization merits wider adoption, health IT, payer groups say
- Electronic prior authorization led to faster turnaround times and higher dispense rates, according to new CoverMyMeds data. More than 60% of ePA requests received a determination in less than two hours compared to 0% of PA requests done over the phone or fax — and they led to an 80% higher dispense rate.
- When electronic PA was combined with a real-time benefit check at the point of prescribing, medication adherence jumped by 20%, the healthcare software company found.
- But provider adoption remains relatively low at less than half of the market, a point of contention between payers and providers. A Health Information Technology Advisory Committee hearing on prior authorization Wednesday similarly reiterated a call for wider adoption while streamlining the snags in the process that prevent physicians, clinics and health systems from getting on board.
Prior authorization, a stipulation that a provider must obtain approval from a payer before prescribing medication or therapy to a patient, is a thorny issue. Proponents of PA herald it as a necessary cost-saving strategy, a control stopping unnecessary care before it's given. The practice saved Medicare almost $2 billion through March 2017, according to the Government Accountability Office, and typically applies to less than 15% of covered healthcare services, according to America's Health Insurance Plans.
Prior authorization has shown some efficacy in paring down unneeded healthcare services. Health insurers report almost 30% of PA requests were for care not supported by clinical evidence, AHIP says.
But providers argue that prior authorization is a burden, and payers need to improve the process to mitigate its impact on patients. According to the American Medical Association, 85% of physicians report the process interferes with continuity of care. A group of Michigan healthcare organizations formed Health Can't Wait to protest PA and step therapy, alleging that requiring approval of certain services before they're delivered delays and disrupts patient service.
AMA, which served on the advisory board for the report, previously published data showing the number of PA requirements has increased in the past five years (in the commercial sector — Medicare fee-for-service doesn't create new documentation requirements for providers). That administrative burden could be because most PAs are obtained through traditional phone or fax methods.
Prior authorization is by no means perfect, especially when it's done manually, payer groups admit. "Automation is obviously a big opportunity here," Kate Berry, senior vice president of clinical affairs and strategic partnerships at AHIP, said at the HITAC meeting.
Electronic prior authorization is a different animal, payers say. Proponents of ePA tout how the practice lowers barriers to medication access and helps speed patients to therapy, two points reiterated in the new study from CoverMyMeds, along with saving additional dollars. The Council for Affordable Quality Healthcare estimates ePA can save $6.84 per transaction.
Electronic PA can also assist low-income populations and can help combat health disparities, according to Melissa Paige, patient access principal coordinator at the University of Virginia Health System, which advised on the report. Paige called the practice and increased transparency into prescription costs "especially important for some of the most vulnerable patients who lack reliable transportation and cannot make multiple trips to the pharmacy if their medication is denied or too expensive to afford during their initial visit."
AHIP is planning to launch an ePA demonstration later this year with two vendors, Berry said. The trial will run anywhere from six to nine months before being evaluated by an independent organization and results published in late 2019 or early 2020.
"The health insurance plans are highly, highly committed to streamlining this process for the patients, the providers and the plans as well," Berry promised.
Payers Humana and Blue Cross Blue Shield of North Carolina, PBMs Express Scripts and OptumRx, and EHR vendors athenahealth and Cerner also served on the advisory board for the report.
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