Streamlining Prior Authorizations and Unlocking Patient Access to Specialty Medications

When Marie D'Orsaneo's rheumatoid arthritis worsened, her doctor prescribed Rituxan, a pricey injectable medication. But her health plan’s approval process dragged on, turning days into weeks. As she waited, her condition deteriorated, forcing her to quit her job, move in with relatives, and seek inpatient care.

Featured in an NBC News broadcast on the high cost of specialty medications in January 20131, D'Orsaneo's ordeal was far from unique. The situation for patients has gotten progressively worse in the years since.

With their high cost and need for special handling and administration, specialty drugs often require a prior authorization (PA). In fact, 71% of infusion therapies prescribed for rheumatologic conditions today require payer approval, according to research published in Arthritis Care & Research.2

But it’s not just the costs that are climbing—so are the hoops doctors must jump through. A staggering 80% of physicians report that prior authorizations are increasing, regardless of whether the drug falls under pharmacy or medical benefits.

For healthcare providers, this process is more than just a hassle—it’s a hazard. Nearly 90% of doctors surveyed by the American Medical Association (AMA) describe the administrative burden of prior authorizations as high or extremely high4.

Prior authorization challenges abound

As if the cost and complexity of specialty medications alone weren’t enough to keep patients from starting and staying on vital therapies, an uptick in the volume of PAs, the near-constant flip-flop of payer rules, and a total lack of provider insight into patient health and benefit information all conspire to make patient access worse.

The journey to get patients with rare and chronic conditions on a highly specialized therapy starts, incredibly, with a web search to determine if a particular medication is likely to require an approval.

Consider the following all-too-typical scenario: A patient presents at a provider’s office with a complicated disease. The physician assesses the situation and quickly determines what treatment is needed. The provider then struggles to figure out if the patient’s insurer will cover the desired treatment. A scavenger hunt of sorts ensues. One staff member rifles through the ubiquitous “payer bible,” a well-worn three-ring binder filled with insurance requirements, while another tries to recall what the insurer has approved in the past. Then, the team must figure out whether the medication falls under the patient’s pharmacy or medical benefit plan, as insurers have different rules for each.

Meanwhile, someone else is making phone calls to payers with one hand and scrolling through insurance websites with the other in a desperate search for coverage information, current policies, and updates. All of this takes considerable time and results in plenty of frustration.

According to a post published as part of the American Medical Association’s What Doctors Wish Patients Knew series, patients might wait days, weeks or even months to receive treatment when PAs are required by insurers. As such, the AMA contends that “existing processes present significant administrative and clinical concerns.”5   

One of the most frustrating hold-ups stems from confusion over whether specialty drugs are covered under medical or pharmacy benefits. For example, infusions, in-office injections and chemotherapy are sometimes covered as medical benefits rather than pharmacy benefits. To complicate matters even more, an estimated 49% of covered individuals have a separate benefit tier for specialty drugs.6

While providers face challenges in obtaining PAs, specialty pharmacies also encounter significant obstacles in ensuring that patients receive their medications promptly. These barriers, though less recognized, are equally detrimental in delaying patient access to necessary treatments.

Of particular concern is the frequent misrouting of specialty therapies to non-specialty pharmacies, which often cannot fill these prescriptions. According to a study by DrFirst, specialty pharmacies are 30% more likely to successfully fill a rheumatological medication than non-specialty pharmacies. However, over a quarter of high-cost specialty medications are mistakenly sent to non-specialty pharmacies, leaving patients in limbo and delaying critical, even lifesaving  treatment.

For the physicians who prescribe these complex therapies, not having access to real-time benefit and pricing information, copay savings, and financial assistance in workflow can severely limit their ability to provide optimal patient care. Despite industry efforts to empower patients and providers with real-time price transparency through new regulations, challenges remain. For example, the ONC’s HTI-2 proposed rule includes a mandate for health IT systems to include functionalities for immediate access to pricing information, but not until 2027 at the earliest.

Even when EHRs offer price transparency, the information is often limited. A provider may identify a specialty biologic drug as the ideal treatment but may not know whether the patient’s insurance will cover it, if approval is required, or if there are any available copay savings or other pricing options.

When this critical information is available at the point of care, providers and patients can collaboratively explore alternative treatments if insurance coverage is unlikely. Discussing price and affordability as part of the care visit helps prevent prescription abandonment due to sticker shock at the pharmacy. In fact, 83% of consumers in a DrFirst survey reported that discussing price with their doctor helped them find an affordable therapy option.

Perhaps most concerning, hub services, which are designed to simplify the process by acting as intermediaries between patients, providers, and pharmacies, are often underutilized. These services provide education and guidance to ensure easy medication onboarding and adherence. However, many patients are either unaware of hub services or do not fully engage with these resources.

These barriers lead to a variety of risks for patients, including:

• Care delays: 94% of physicians report prior authorization contributes to care delays 'sometimes,' 'often' or 'always.'
• Care disruptions: 89% of physicians report that prior authorization interferes with continuity of care.
• Adverse outcomes: 33% report that prior authorization has led to a serious adverse event for a patient in their care.7

Perfecting an imperfect process

To overcome medication access challenges, electronic prior authorization needs to seamlessly exist within a healthcare organization’s existing workflow. An electronic solution should streamline the entire process by offering real-time medical benefits and automating the PA process from end to end.

In addition, it’s important for providers to adopt a platform that leverages AI, machine learning and robotic process automation to streamline complex benefits pricing and processes for both pharmacy and medical benefits. A platform that readily engages patients and offers unified medication management can also help facilitate access to needed therapies.

As Colin Banas, chief medical officer at DrFirst, explains: Providers can reduce manual effort by more than 70% and cut claims rework by 90% when using a system that automatically prescreens PA errors and provides a dashboard for monitoring the status of requests.

“Leveraging a platform with all these components is a significant step toward easing prior authorization burdens for providers and pharmacies, and the benefits extend to payers and pharma, as well. Most of all, though, it’s a giant leap forward for all those patients who previously suffered as their health deteriorated and their lives were put on hold because they were not able to access the treatment their doctor determined was right for them when they needed it most," said Banas, M.D., M.H.A.

Timely by DrFirst is a personalized mobile communication experience that works to improve medication adherence in partnership with life science brands. Timely is built on the strength of e-prescribing pioneer DrFirst’s EHR integration and complemented by streamlined access to specialty medications covered under medical benefits. Timely extends the reach of prescribers to support the patient journey where and when it matters most – at the point of inception – when patients are making the decision to start treatment. 

References

1. Kingsbury, K. If you can’t pay: How to get insurance to cover specialty drugs. NBC News. https://www.nbcnews.com/healthmain/if-you-cant-pay-how-get-insurance-cover-specialty-drugs-1B8033714
2. Wallace, Z., Harkness, T., Fu, X., et.al. Treatment delays associated with prior authorization for Infusible medications: A cohort study. Arthritis Care Research.
3. American Medical Association. 2023 Prior authorization survey. 
4. Ibid.
5. American Medical Association. What doctors wish patients knew about prior authorization.
6. Kaiser Family Foundation. 2021 Employer health benefits survey. 
7. American Medical Association. 2023 Prior authorization survey.