Electronic Prior Authorization On the Radar to Improve Medication Access

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by Tony Schueth, CEO & Managing Partner

A growing number of medications require prior authorization (PA) before they can be dispensed. This is a concern among providers, who are very troubled about the impacts. And they can be detrimental to patients’ health. A recent survey by the American Medical Association (AMA) found that more than 9 in 10 physicians (91%) said that the prior authorization process delays patient access to necessary care. Three-quarters (75%) report that prior authorization leads to patients abandoning a recommended course of treatment.  A similar percentage found that PA processes cause adverse events.

These disturbing findings are the latest in a litany of problems that have long been associated with today’s costly and antiquated PA processes. In response, the industry will be doubling down this year on electronic processes to streamline PAs and benefit checks for drugs covered under the patient’s pharmacy benefit as well as those covered under the patient’s medical benefit. This will make PA submissions and responses for drugs faster and easier, prevent delays in treatment and find affordable therapies.

This is where we see accelerated activities around ePA:

  1. The industry will settle on a standard for the real-time pharmacy benefit check (RTPBC). We include the RTPBC in the ePA section because our research shows that payers care about its ability to indicate the need for PA. (Click here to learn more about our study findings.) The RTPBC is a transaction that can be used in the ePrescribing process to provide patient-level formulary benefit details, such as patient out-of-pocket cost, drug alternatives and flags indicating that PA is required. It enables providers to make better informed medication choices at the point of prescribing and helps connect patients with the costs of their care. There are currently three ways to facilitate an RTPBC: 1) proprietary or via one of two standards, 2) National Council for Prescription Drug Programs (NCPDP) SCRIPT (ePrescription) or 3) Telecomm (the pharmacy claim). The industry won’t be able to settle on one transaction standard; instead, it will be a compromise between the two.
  2. The implementation deadline for adoption of the RTPBC by Medicare Part D will be moved back from January 1, 2020. The 2020 date was recently proposed under a regulation from the Centers for Medicare and Medicaid Services (CMS) entitled Modernizing Part D and Medicare Advantage to Lower Drug Prices and Reduce Out-of-Pocket Expenses, CMS-4180-P. A one-year preparation period doesn’t provide enough time for electronic health record (EHR) vendors and others to incorporate the transaction into their products and workflows. That’s why we think the implementation date will be moved back. Regardless of when Part D adopts the RTPBC, it will drive adoption by the industry. (Click here to read our comment letter on the proposed rule).
  3. Substantial progress will be made on electronic medical prior authorization (eMPA), a standardized electronic method for handling PAs for drugs, devices and procedures covered under a patient’s medical benefit. We are participating in and tracking no fewer than a half-dozen separate, industry-led conversations to reduce or remove PA and provider burden.
  4. There will be experimentation and innovation regarding removing PA as a requirement. Payers will publish more policies indicating that if certain conditions are relevant, PA isn’t required. Others will try more “gold carding” where payers allow certain specialists that meet quality criteria to proceed with expensive procedures without PA. Payers’ engines will get smarter, not requiring PA when it’s a completely unnecessary action.
  5. We will see incremental progress to standardize and automate delegated ePA. Delegated ePA is when payers and providers send prescription drug ePA requests to a third-party for processing; some vendors also manage PA for the drugs, devices and procedures covered under the patient’s medical benefit. We think other rapidly evolving efforts in ePA will push stakeholders to get off the dime. So far, they have not been interested in stepping up.
  6. There will be greater integration of ePA in EHRs. Research indicates that 73% of the EHR market in 2018 had already integrated an ePA solution. There are various flavors of these implementations, which will begin to coalesce around federal and state requirements. The recently enacted federal opioid legislation mandates ePA for Part D covered drugs by January 1, 2021. A standard was not named, but we predict CMS soon will name one. A growing number of states are creating and enacting ePA mandates. (Learn more about state ePA laws from our Regulatory Resource Center.)

The Point-of-Care Partners team is actively engaged in a wide range of activities related to the development and adoption of ePA. Want to know more or become involved? Reach out to me at tonys@pocp.com.



In this video, Tony provides insights about some of the company's 2018 health IT predictions and why he thinks electronic prior authorization will be front and center in 2019.