Prior Authorization
Ariel L. Clark, PharmD
“Your prescription requires prior authorization.” A statement heard far and wide across the health care system and one that pharmacists and pharmacy technicians are intimately familiar with. Since the 1960s, when the prior authorization process first began with the staggering increase in drug costs, prior authorizations have become part of the “standard operating procedure” for everyday pharmacy practice.
In a recent letter published May 8, 2022, in the American Journal of Health-System Pharmacy (AJHP), Choi and colleagues detailed the heavy burden of prior authorizations on the U.S. health care system, the impact of using specialty pharmacy practitioners to ease some of that burden at a university medical center, and what could be the new “gold card” standard for the prior authorization process.
Prior authorization burden
While prior authorizations exist as a consistent part of the provision of health care, they also represent a heavy lift on practitioners that can lead to negative results for patients.
Authors of the AJHP letter cited the 2020 American Medical Association PA Physician Survey, which noted that the process of prior authorization, either for medications or procedures, results in “a significant medical event.” These medical events can include hospitalization for new or worsening conditions, life-threatening incidents, and even death while patients wait for a therapeutic intervention. According to Jack Resneck, MD, AMA president, medical events like these increase health care costs—which is the exact reason behind the development of the prior authorization process in the first place. Resneck published “Refocusing prior authorization on its intended purpose” in JAMA in 2020.
Financing the prior authorization process represents another significant burden in its own right, according to the AJHP letter. Authors again reflected on the 2020 Physician survey, which reported over $500 million in the administration of prior authorizations largely due to the staff of physicians who process them.
Specialty pharmacies’ role
With the evolution of biologics and advanced drug therapies, the establishment of specialty pharmacy practice was born. This unique practice surfaced over 5 decades ago as an avenue to decrease costs and increase access to necessary medications. In addition to cost and access, authors note that specialty pharmacies have also taken on additional patient care services, which include patient education, shipping coordination, and processing prior authorizations.
Choi and colleagues, all faculty at the University of Chicago Medicine (UCM) Department of Pharmacy, noted that the university established its specialty pharmacy in 2015, and it grew from a staff of 2 to 25 in a short 4 years. They sought to determine the impact of their department handling the prior authorizations for medications in the outpatient setting within their system.
UCM used an online tool called CoverMyMeds to electronically process prior authorizations. This tool has been available since 2008 and is commonly used by physician offices and pharmacies across the country. Authors collected all prior authorizations submitted in an 11-month period within the UCM domain, which totaled 12,331. Twenty members of the specialty pharmacy team, which included 4 pharmacy technicians, accounted for 52% and 49% of the submitted prior authorizations for the health system, respectively.
Not only did the specialty pharmacy team at UCM handle the majority of the electronic submissions, but they were also able to do so with an approval rate of 97%. And in the cases of those that were originally denied, the authors describe that their team was able to overturn those denials in 70% of cases.
Barriers to evidence-based medicine
Choi and colleagues referenced another study in their letter where Lenahan and colleagues found that commercial insurers contradict guideline-directed therapy through step-therapies.
In an effort to mitigate the barrier to guideline-directed therapy that prior authorizations create, the state of Texas, for example, passed legislation that will allow providers to properly provide patient care in certain circumstances if they achieve at least a 90% prior authorization approval rate—“gold card” status—with certain insurers and for certain medical procedures.
Given the high burden that prior authorizations create for providers, and the environment they create that potentially limits best medical practices, authors of the letter are left wondering if the Texas “gold card” approach should also apply to medications and extend beyond the borders of Texas. ■