Insurers have always advocated the benefits of prior authorization (PA) adducing studies that illustrate the reduction of costs. Even then, providers hesitate to utilize PA processes because of excess paperwork and varying patient care needs. Manual PA processes usually result in the creation of administrative burdens, and according to multiple case studies on PA processes, bringing the authorization process into electronic health records (EHR) shows potential in relieving this stress. To support the movement of PA into EHRs, a group of stakeholders, such as the American Hospital Association, American Medical Association and other reputable healthcare institutions, are coming together. Further, centers for Medicare services are now encouraging Medicare Advantage plans to use PA for reducing the use of costly drugs in doctors’ offices through Part B of Medicare.
According to a report released by a government accountability office, Medicare PA saved between $1.1 and $1.9 billion by March 2017. A 2018 report on the electronic prior authorization (ePA) National Adoption Standard by CoverMyMeds revealed that about 10 percent of prescription claims are rejected by pharmacies. Concurrently, EHR companies are selling their products and services as solutions that will help patients take their medicine without having to worry about PA hurdles.
“PAs create significant barriers for family physicians to deliver timely and evidence-based care to patients by delaying the start or continuation of necessary treatment,” reads a statement from the American Association of Family Physicians. A third of the physicians that took part in an Against Medical Advice (AMA) survey reported a waiting period of at least three business days for a payer to give the OK when using legacy PA processes. Alternatively, companies like Surescripts and CoverMyMeds promise providers the ability to complete a request in minutes, owing to their plan that incorporates ePA system into EHRs.
Today, with pharmacy ePA gradually becoming the norm, the next step in their development is faster decisions with respect to tests and procedures. However, this transition will not be straightforward because ePA processes for prescriptions only require working with a dozen pharmacy benefit managers whereas authorization for tests and procedures will require working in tandem with hundreds of health plans.