Electronic Prior Authorization
Despite the availability — and proven benefits — of an electronic solution, half of prior authorization volume still occurs through phone and fax channels. We explore what’s causing the lag in adoption, how optimization may impact the use of an electronic solution and the potential impact of adoption on patients’ access to the medications they need to live healthy lives. Read the full report below or download the executive summary.
The benefits are widely known: When a prescription prior authorization (PA) is submitted electronically, patients get their medications faster and are more likely to adhere to their prescribed treatment.
Because of this, electronic prior authorization (ePA) has been embraced across the healthcare network: Today, nearly 100 percent of pharmacies, payers and electronic health records (EHRs) have an ePA solution.
Yet, despite rapid integration of ePA over the last decade, nearly half of PA volume is still submitted through traditional channels like phone and fax.
In this sixth installment of our Electronic Prior Authorization National Adoption Report, we expand our focus on provider* adoption of ePA — examining the implications for patients’ access to medication, as well as how optimization of ePA may lead to greater adoption.
Continued education of the benefits of ePA may encourage provider adoption. The healthcare network should continue to update current processes to limit the use of outdated PA channels and to help achieve provider adoption across the board. Focus should shift, too, toward the benefits of prescription decision support (PDS) solutions that include ePA, making the prospective PA requests a more organic part of a prescriber’s workflow.
As health systems continue to grow at a rapid pace, ensuring an ePA solution is readily available will not only help reduce provider burden but may also benefit patient health. Data shows that the adoption of ePA through EHR systems and health systems correlates with a decrease in time to therapy and, overall, an increase in patient medication adherence.
*We define “provider” as a prescriber and any member of their care team, inclusive of nurses, medical assistants, office managers and prior authorization specialists.
Status of ePA
Understanding factors that influence provider adoption of ePA is critical for industry-wide success of the solution, as more than half of all PA volume still occurs over the phone and by fax.
Prior authorization requests can be started at the point of prescribing (prospective) or following claim rejection (retrospective), typically at the pharmacy.
A recent case study illustrated that patients access their medications an average of 13.2 days sooner when requests are submitted prospectively versus retrospectively. Nevertheless, retrospective ePA volume continues to outpace prospective ePA volume, suggesting providers may not be aware of the true time and cost savings available through prospective ePA.
In a recent survey of 400 providers, 60 percent of respondents reported that their practice completes PA requests retrospectively, after the pharmacy has notified them that PA is required. Twenty percent reported that they complete requests after a patient has notified them of a PA requirement, while just 17 percent reported that they start a PA at the point of prescribing.
One reason providers avoid starting PA requests at the point of prescribing? They don’t fully trust the plan formulary information supplied in their EHRs. Sixty percent reported they only sometimes trust the insurance data available in their EHR, while 19 percent reported they rarely or never trust this information.
Emerging real-time benefit check (RTBC) technology can supply providers with high-accuracy patient information at the point of prescribing, providing visibility into PA requirements for a prescription. Already, RTBC and ePA are utilized as a powerful combination to increase speed to therapy.
An RTBC solution may not persuade a provider to complete a PA request prospectively. In fact, with this data, a provider may decide to prescribe an alternative medication that doesn’t require PA or help their patient find a cash option. Yet, greater insight into options at the point of prescribing may result in more consistent, confident PA processes.
What's Inhibiting Total ePA Adoption?
Despite evidence that the use of an electronic solution results in faster PA determinations, 49 percent of providers reported occasionally using non-electronic methods (i.e., phone and fax) to complete PA requests for certain situations.
Though 62 percent of PA requests submitted electronically receive a determination within two hours, and 43 percent receive a determination automatically, 33 percent of providers still choose phone or fax over ePA to complete urgent requests.
Twenty-eight percent of providers surveyed said they revert to non-electronic methods when handling a complex prescription situation, 20 percent automatically use non-electronic methods when they’re unsure if ePA is an option for a specific plan and 19 percent choose manual submission for specialty medications.
The Evolution of ePA
Due to the overwhelming number of retrospective PA requests, it’s often the pharmacist who’s responsible for answering patients’ questions and initiating the PA.
While the industry’s long-term goal should be to empower providers to start PA requests prospectively with the help of an RTBC tool, a near-term solution is the use of an automatic pharmacy PA solution.
This technology automatically initiates a PA request when one is likely to be required based on historical data, notifying the provider of a rejection and resolution option and decreasing the likelihood that a prescription is abandoned.
Understanding Administrative Burden
Providers report spending significant time on administrative processes like PA. In addition to greater education on the benefits of ePA, optimization of the solution is critical for increasing provider adoption.
While intended to control costs, reduce unnecessary prescription drug use and optimize patient outcomes, PA can create a significant administrative burden for providers. In fact, 86 percent of physicians believe the burden of PA is high or extremely high, while 88 percent feel the burden of PA has increased in the last five years.
On average, providers spend 14.9 hours — approximately two business days — on their PA workload.
In a survey, 1,453 providers outlined the challenges plaguing the PA process and the benefits of ePA. Despite these benefits, more than half of all PA volume still occurs through phone and fax channels.
This manual, time-consuming process has implications beyond the doctor’s office, affecting pharmacies, health plans and, ultimately, the patient.
According to the American Medical Association’s most recent survey on the topic, the provider burnout rate has, for the first time since 2011, dropped below 50 percent. In a survey of more than 5,000 physicians, 43.9 percent reported at least one symptom of burnout (emotional exhaustion, feelings of cynicism and detachment from work, and a sense of low personal accomplishment), compared with nearly 55 percent in 2014.
Despite this positive shift, there are opportunities, especially within the PA process, to reduce burnout further.
Twenty-six percent of survey respondents reported that, as the result of administrative work like PA, they’ve seen a reduction in face-to-face time with patients. Sixteen percent reported that they have less time to interpret lab and scan results, and 16 percent reported they experience less staff interaction.
In another survey, 71 percent of nurses were less than satisfied with the amount of time they spend on the phone dealing with insurance issues, such as PA.
Prospective submission via an existing PA workflow can help a provider get ahead of the additional work that often arises when a PA requirement isn’t realized until the claim is rejected at the pharmacy. Submitting PA requests at the point of prescribing often results in significantly faster completions, leaving providers more time to engage with the work they want to prioritize.
Increased provider adoption of ePA has positive implications for the rest of the network, too. When a provider submits a PA electronically, they’re notifying the health plan and pharmacy sooner. This communication and coordination among network partners leads to better outcomes for patients: A medication is more likely to be dispensed (i.e., picked up by a patient) if the turnaround time for the PA process is short. Using phone and fax for PA requests can delay medication dispense by a full day.
Greater optimization of an electronic solution may encourage providers to reject phone and fax channels in favor of ePA. We recommend providers couple ePA with an RTBC solution during the ePrescribing process and shift from retrospective to prospective PA submission, and that health plans and prescription benefit managers (PBMs) update and modernize existing technical infrastructure and processes related to PA.
Centralized PA: Streamlining the Process
Electronic prior authorization was developed with providers in mind, with a goal to reduce their administrative burden — and to enable patient- and drug-specific PA in real time.
And across health systems, a trend is emerging: Centralized teams of administrators dedicated to completing PA requests, a staffing shift that may positively impact provider burden — and reduce PA burnout.
According to a recent American Medical Association survey, 36 percent of physicians have staff who work exclusively on PA.
One-third of those surveyed reported they use a centralized approach for PA. They noted faster completion, consistent processes and lower administrative burdens as benefits.
ePA and Patient Impact
The use of ePA over traditional phone and fax channels has positive implications for patients’ access to medication, significantly reducing time to therapy.
In a recent provider survey, 91 percent of respondents reported that PA results in delayed access to necessary care. In the same survey, 75 percent of respondents reported that the PA process has led to patients abandoning treatment altogether.
In a different survey of 1,000 people, 55 percent reported delays in time to therapy due to a prescribed medication requiring PA.
Prescription abandonment increases the risk of future health problems or hospitalization. The utilization of an electronic solution may increase patient medication adherence by helping to ensure patients leave the pharmacy with prescription in-hand.
When a patient perceives they have access to the medication prescribed for them by their provider, the probability that they’ll pick up their prescriptions and adhere to therapy increases.
Not only can accelerated turnaround times on ePA determinations affect dispense rates at the pharmacy, the improved patient perception of access to medications can translate to a three percent greater likelihood that patients will pick up their prescriptions from the pharmacy.
ePA and Specialty Medication
For patients prescribed specialty medication, delays in time to therapy can be significant. Though prescribing these medications is far more complex for all involved, the use of ePA is still beneficial.
Due to an aging population, a growing number of Americans with complex and chronic diseases and a shift in drug manufacturing trends, specialty medications are the fastest-growing segment of U.S. drug spend.
While there is no specific definition for what constitutes a specialty medication, it is generally agreed they are high-cost brand-name or generic medications (average wholesale acquisition cost of more than $670) for patients suffering from complex or rare diseases.
The inherent complexity of specialty medications — unique administration (nebulizer, injections, infusions) and the need for consistent patient monitoring — is compounded by time-intensive up-front processes. In addition to PA, these include enrollment documentation, benefit verification and risk evaluation and mitigation strategies (REMS).
In fact, in a recent survey of 1,000 people, 60 percent of those currently prescribed a specialty medication reported experiencing at least some level of difficulty in obtaining their first dose.
When asked to rate the difficulty for starting patients on complex medications, 81 percent of survey respondents reported that the process is at least slightly difficult. Despite working well for approximately half of all specialty claims (i.e., those covered under the pharmacy benefit), ePA is still not widely recognized by providers as a solution for specialty medications.
In the same survey, 19 percent of respondents reported that they’re inclined to use phone and fax over ePA for specialty medications.
The Impact on Access and Adherence
A patient’s journey for specialty medications involves safety and educational components, as well as reimbursement protocols, that can collectively delay time to therapy three to six weeks, for some therapeutic areas.
Electronic prior authorization for specialty medications can reduce time to therapy significantly, from 17 days to as few as 1.5 days.
Continued advocacy of ePA at the federal and state levels highlights the industry’s commitment to modernizing healthcare and protecting patients.
H.R. 6, the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act, was signed into law on October 24, 2018.
Within H.R. 6 is a provision (Section 6062) stipulating utilization of ePA for drugs covered under Medicare Part D by January 1, 2021. This law requires the Centers for Medicare and Medicaid Services (CMS) to install regulations mandating Medicare Part D plans to accept PA requests submitted electronically — and requires the Secretary of Health and Human Services to consult with standards development organizations, including NCPDP.
Additionally, beginning January 1, 2020, the Centers for Medicare & Medicaid Services will require that Part D ePrescribing be conducted using solely the NCPDP SCRIPT Standard Version 2017071.
The opportunity to adopt the NCPDP SCRIPT Standard to expedite prescription PA is an opportunity for the Secretary to ensure the Medicare Part D program is utilizing a prevalent standard used in other markets today. The standard named by the Secretary must be implemented.
Types of Legislation
Many states are also adopting legislation around PA and ePA, with laws ranging from use of a standardized form for submission to mandating the use of the NCPDP SCRIPT Standard for ePA.
ePA (NCPDP Standard)
Calls for the use of an electronic method for submitting medication PA in compliance with the NCPDP SCRIPT Standard.
ePA (No Standard)
Calls for the use of an electronic method for submitting medication PA, but names no standard.
Standard Form & ePA
Calls for the use of a universal or standard form as well as the use of an electronic method for submitting medication PA.
Calls for the use of a universal or standard form for medication PA approved by the state’s Department of Insurance.
Legislation by State
The increase in legislation around PA and ePA has become more prevalent at the state level. Mandates range from use of a standardized form for submission to mandating the use of the NCPDP SCRIPT Standard for ePA.
Beyond the Standard Form
Though PA legislation has a positive impact on the industry, it’s important new legislation aligns with the most cutting-edge ePA technologies to make the most impact on streamlining PA.
While well-intentioned, laws requiring exclusive use of a standard form (despite pre-existing availability of ePA solutions) can inadvertently displace inefficiency, as the standard form cannot address all specific-use requirements that can arise during the PA process for various medications.
Looking ahead, it’s critical state legislators consider the availability of ePA solutions already active in their states and allow provisions for its use in standard form legislation to prevent unnecessary burden.
Completing PA requests through a manual process involving phone calls and faxes between pharmacies, providers and health plans is an inefficient, time-consuming process — and poses a significant medication access challenge for patients, one that often leads to prescription abandonment.
The adoption and optimization of an electronic solution — one that allows providers to complete prospective PA requests in their EHR or an ePA web portal — has the potential to not only simplify provider and pharmacist workloads, but also increase speed to therapy for millions of patients each day.
The Electronic Prior Authorization Report is written and published by CoverMyMeds with guidance from industry experts on the Advisory Board for the overarching Medication Access Report.