Payers, Providers Speed Care by Agreeing on What Does Not Need Authorization
The prior authorization process is nothing short of infuriating to patients and medical staff, the authors of a study concluded.1
Even before starting their research, the investigators were well aware of this reality. “We knew the process was burdensome not just for the patient, but also for the clinician and office staff,” says Michael Evans, RPh, one of the study’s authors and vice president of enterprise pharmacy and chief pharmacy officer for Danville, PA-based Geisinger Health System.
Researchers conducted focus groups with 13 patients insured by an affiliated health plan. All had at least one medication claim denied in the previous year. “Patients don’t understand the process,” Evans says. “They get frustrated because after being diagnosed with a disease, they need therapy. Sometimes, it takes weeks for prior authorization to go through.”
Investigators also conducted focus groups with nine physicians and office staff. This group viewed authorizations as “a lot of extra work that adds no value,” Evans reports.
A strong theme of frustration, anger, and anxiety emerged. Patients said they needed an advocate. Providers said they needed a list of medications requiring prior authorization. “We knew before this study that the process was antiquated and broken,” Evans says. “We needed to do something about it.”
Prior authorization first came about under a fee-for-service model. Geisinger Health System (and healthcare in general) is moving to a value-based model with revenue tied to efficiency.
“That means eliminating prior authorizations, which are not adding value and are actually adding cost,” Evans explains. At Geisinger Health System, some important changes were made to keep prior authorizations from interfering with patient care, specifically for people insured by the Geisinger Health Plan. “We are practicing evidence-based medicine. We didn’t want the prior auth process getting in the way of that,” Evans says.
The amount of time spent on prior authorization varies significantly based on medication and payer. “Presenting providers with evidence-based clinical pathways standardizes drug selections. It eliminates the need for excessive processing time,” says Ann Marie Petrochko, RPh, who is leading Geisinger’s redesign of prior authorization processes. Petrochko is director of pharmacy operations at Geisinger’s CareSite Specialty Rx.
Some medications are approved 99% of the time. For these drugs, securing authorizations is a waste of time and money for both payers and providers, according to Evans. On the other hand, some drugs need prior authorization for patient safety. “The problem was that the application was too broad,” Evans observes.
To help patients receive the treatment they needed faster, an agreement was reached to limit the number of medications that needed prior authorization. “This is the direction we all need to go in,” Evans offers.
The health system is closely tracking patient outcomes. “We don’t just do this and walk away. We have monitoring around it on a high level,” Evans says. “But we don’t get in the way of day-to-day patient care.”
Prior authorizations typically result in cost savings for payers and higher costs for providers. “But when you remove the prior auth, and you are in value-based care, you remove the expense, and you increase access to the appropriate therapy,” Evans says.
With this model, the payer’s quality metrics also should improve. “If payers are aligning their formulary and contracts with best practices, they should be financially in a better position as well,” Evans explains.
Pennsylvania’s Medicaid program recently created its own Preferred Drug List. This means all managed care organizations have to follow this formulary for Medicaid patients. “This creates a criterion where we need prior auth, no matter what. That is not a direction we want to go in healthcare,” Evans says.
If prior authorizations are eliminated with upfront agreements, it frees up patient access staff. Registrars can instead help patients understand their coverage and out-of-pocket costs. “That’s a gap today, and it’s growing faster than we are plugging it,” Evans adds.
- Jones LK, Ladd IG, Gregor C, et al. Understanding the medication prior-authorization process: A case study of patients and clinical staff from a large rural integrated health delivery system. Am J Health Syst Pharm 2019;76:453-459.
If prior authorizations are eliminated with upfront agreements, this can create more time for patient access staff. Registrars can focus on helping patients understand their coverage and out-of-pocket costs.
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