Prior authorization was created by the insurance industry to provide the most appropriate and cost-effective healthcare services and medications for patients. Since its development, pharmacists have continued to see an annual rise in the number of prior authorizations by 20%; this is a momentum that is expected to continue as specialty medications increase. In fact, there is a direct correlation between the availability of specialty and new medications, and a rise in prior authorization volume.
Although prior authorization generally improves the use of evidence-based treatments and reduces prescription costs, barriers to care can also be attributed to this tool. At the pharmacy level, we are seeing nearly 40% of prescriptions that require prior authorization go unfulfilled, and up to 70% of patients encountering prior authorization are provided with an alternative therapy. Such hurdles can lead to a delay in care or abandonment of therapy, which can, in turn, contribute to nonadherence, rising healthcare costs, and ultimately impact patient health outcomes.
Taking a Patient-Minded Approach
To improve patient health and outcomes, pharmacists are taking an increasingly patient-minded approach to care and business operations, spending more time interacting with customers. With specialty medications increasing more than 26% just last year, the role of the pharmacist continues to evolve to healthcare provider and wellness center, in addition to business manager. As pharmacists do more than ever in their day-to-day roles, balancing these tasks becomes increasingly more challenging. And with the vast majority of specialty medications requiring prior authorization, pharmacists require the right tools—at the right time—to manage the process in a more efficient way. Tools that ease the administrative burden of prior authorization, such as electronic prior authorization services, allow physicians and pharmacists to collaborate on the process.
Electronic Prior Authorization Services
Although electronic prior authorization services can, in general, move the process into an electronic format, the functionality of these services can vary, depending on the vendor, payer, pharmacist, and provider preference. Electronic prior authorization services require the use of Health Insurance Portability and Accountability Act–compliant software that can easily integrate with nearly every pharmacy system. Some services simply offer a methodology for providers to complete and submit forms electronically, whereas others are fully integrated into electronic health records and manufacturer hub services. Cohesive services increasingly streamline the process, as patient information can be autopopulated into standard forms, saving time and resources.
Traditional prior authorizations take an average of 15 minutes to complete, but pharmacists and providers using an electronic prior authorization service, such as CoverMyMeds, reported spending an average of 1 to 3 minutes to complete the process electronically. Electronic prior authorization services also allow payers to approve the therapy in real time, and help patients access their medication during their first visit to the pharmacy. CoverMyMeds reported that its systems see real-time approvals approximately 30% of the time, and the rate continues to increase.
Another tool that can help pharmacists streamline the process through electronic prior authorization is RxRescue.1 Developed by Lash Group, a part of AmerisourceBergen Corporation, RxRescue was created as a way to avoid prescription abandonment and increase completed scripts by intercepting prior authorization at the pharmacy.
With more than 20 years of experience in the design and delivery of patient programs that improve product uptake and adherence, Lash Group regularly works with manufacturer to help patients overcome barriers they can encounter with specialty medications, including prior authorizations.2 After evaluating the available electronic prior authorization products on the market, Lash Group saw a need for a more streamlined approach, and partnered with CoverMyMeds to provide pharmacists with the support they need to ensure patients have access to treatment at the point of sale. Manufacturers already committed to patient access are now able to provide an additional layer of support to community pharmacies by implementing RxRescue within the providers' and pharmacists' already preferred workflows. This tool helps intervene on prior authorizations at the pharmacy to prevent changing the prescription from what the physician intended, and saving scripts from abandonment, which are all critical to ensuring each patient is receiving the best possible care.
To put the need for this type of offering into perspective, over a 6-year period (from 2007 to 2013) the percentage of medications requiring prior authorization nearly tripled, and that growth continues to this day. Learning how to respond and collaborate on prior authorization requirements is key for pharmacists as we look to 2016 and beyond. Many options exist for supporting therapies that call for prior authorization and reimbursement. Using electronic prior authorization systems, such as RxRescue and/or CoverMyMeds, pharmacists can streamline their processes, enhance store efficiency, and provide the highest quality patient care.
- Lash Group. RxRescue. www.lashgroup.com/technology/RxRescue. Accessed December 29, 2015.
- Lash Group. About us. www.lashgroup.com/about. Accessed December 29, 2015.