Although provider adoption of ePA solutions averages at 47.5 percent according to payers representing 96 percent of market share,40 individual payers have demonstrated provider adoption as high as 87 percent following ePA integration.41
This success was realized by a regional health plan that enabled auto-determination for ePA and implemented operational changes directing providers to the electronic channel versus traditional methods of phone or fax (i.e. explicitly directing providers to use ePA).41
In contrast, the top five PBMs by market share demonstrate provider adoption of ePA at 51 percent and may benefit from the provider adoption tactics used by successful regional health plans.41
Payers providing coverage for commercially insured patients typically see greater provider adoption than programs servicing patients covered by government programs, which could suggest that providers do not perceive ePA as a solution for Medicare and Medicaid and/or that Medicare and Medicaid payers do not quickly integrate ePA solutions. For instance, despite 87 percent provider adoption overall in the above example, electronic submission for PA requests for Medicare Part D drugs lagged behind by 17 percent.41
Communication and operational changes from payers on ePA are key drivers for provider adoption. Such changes include transparency around availability limitations, indication that ePA will work for Medicare and Medicaid and the potential for auto-determinations. Payers can also make a difference through fax back responses encouraging providers to use ePA for completing requests.
Indicating a payer is live with ePA does not mean all medications or plans—in the case of a PBM—use ePA functionality. The majority of payers initially activate ePA for a select number of medications or plans that they service while they work toward electronic incorporation of all criteria, which differs by plan and medication.
As more providers complete PA requests electronically, payers can expect to extract the most benefit from ePA solutions, including:
|Argus Health Systems|
|Envolve Pharmacy Solutions|
|Mayo Clinic Health Solutions|
|Moda Health Plan|