March 20, 2019
Dive Brief:
- 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.
https://www.healthcaredive.com/news/electronic-prior-authorization-merits-wider-adoption-health-it-payer-grou/550937/
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