Reducing the Negative Side of Prior Authorization

Guest post by Robert S. Oscar, R.Ph. CEO and president, RxEOB.

Robert Oscar
Robert Oscar

Prior authorization exists to reduce drug costs, to manage appropriate brand medication prescribing, and to curb medication abuse. Despite its good intentions, this extra step to determine whether or not a drug is appropriate for a patient’s symptoms has gained a reputation of inconvenience for both physicians and consumers.

In a 2013 study by SUNY Upstate Medical University, it was revealed that U.S. primary care physicians and their office staff have experienced significant increases in time consumption as a result of prior authorization and its associated requirements. For consumers, hours can be wasted waiting to find out whether or not they are allowed a particular prescription under the conditions of their health plan.

Reducing this negative aspect of prior authorization is paramount for the betterment of overall health costs and medication adherence. By streamlining the time spent between medical record lookup and prescription delivery, healthcare organizations and consumers can begin to experience more efficient prior authorization. If efforts made toward better big data advancements, mobile health (mHealth) and health IT are prioritized, doctors can confirm drug eligibility faster to help their patients recover faster.

Below are five reductions that can come from implementing electronic prior authorization (e-PA):

Reduced Labor Costs: When a doctor pulls up a patient’s medical records he must sift through numerous data points to determine which drugs are approved and which drugs are going to require prior authorization. The hours spent processing this data is costly for healthcare staffing, but lost time can be reduced by moving the process online and implementing electronic methods. This can allow physician offices and PBMs the ability to review, submit and determine authorization almost immediately.

Reduced Consumer Delays: A consumer will typically experience the unattractive side of prior authorization at the pharmacy. If a doctor issues a prescription without knowing the patient’s medication history or pushes a popular name brand drug without suggesting a generic, the consumer will likely get sidelined with prior authorization processing at the point of sale. Having an e-PA process that can review and determine which drugs a patient is already approved for before they head to the pharmacy can reduce customer wait times and greatly increase consumer satisfaction.

Reduced Compliance Issues: Because the Centers for Medicare & Medicaid Services play a role in prior authorization, non-compliance issues can result if reporting is not conducted properly. The chances of compliance audits can be greatly reduced if the reporting of all prior authorization processing and its associated timelines are structured electronically.

Reduced Drug Costs: The number of drugs that require prior authorization is less than 100, and many of them fall into the category of big-name, blockbuster prescriptions. These costly varieties frequently have generic counterparts that are much cheaper and can be had without prior authorization. The process of determining drug availability through an e-PA process can determine what generics are available for a given symptom much easier than traditional methods and help reduce the overall cost of health care.

Reduced Drug Abuse: Doctors can help encourage electronic prior authorization efforts that aim to reduce the number of prescription abuse cases by working faster to pull medical records. Because controlled substance abusers will try to source drugs from different doctors, placing an extra step of approval in between the initial visit and the prescription can help reduce this problem.

Prior authorization does not have to be a detriment to the U.S. healthcare system. Through the use of big data, mHealth and other health IT tools, PBMs and physicians can greatly reduce a number of cost, compliance, and patient service issues associated with prior authorization. While challenges with interoperability, electronic medical records, and insurance carrier competition exist, collaborative investments in the e-PA process will eventually help identify and reduce the negative side effects of prior authorization.

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