Michigan Association of Health Plans

Taking the Pain Out of Prior Authorizations

Anyone who has been treating patients with specialty pharmacy medications for even a short time has likely encountered the challenge of navigating prior authorizations (PAs). So it may be of interest to keep up with the latest efforts to ensure the PA process is fair and equitable and does not unduly impede access to potentially lifesaving medications.

A good place to start is to become familiar with the new best practices released from the Academy of Managed Care Pharmacy’s (AMCP’s) Professional Practice Committee. According to the document, published in the June 2019 issue of AMCP’s Journal of Managed Care & Specialty Pharmacy (2019;25[6]:641-644), managed care organizations should focus on nine core concepts to improve PAs (see box, next page) and ensure the processes involved are timely, transparent, collaborative and supportive of patient-centered care.

“Prior authorization is an essential tool for helping to optimize patient outcomes, reduce waste and errors and unnecessary drug use, as well as costs,” said Cynthia Reilly, AMCP’s chief operating officer. “But there is variability in how PA is applied and how it works with different players and parties in the system who engage in that work.”

To help address that variability, “the Professional Practice Committee developed this paper in order to define what best practices look like,” Ms. Reilly added. “Ideally, we hope that this will be a resource to help drive adoption of best practices, as well as some standardization across the board.”

Providers, patients and advocacy groups have been frequent and vocal critics of the PA process. In February, the American Medical Association (AMA) released a survey of 1,000 practicing physicians about the effects of PA policies on patient care. More than nine in 10 respondents said PA had a significant or somewhat negative clinical impact, with 91% reporting significant delays and 28% reporting that the delays had led to a serious adverse event— such as death, hospitalization, disability or permanent bodily damage, or other life-threatening event—for one of their patients.

“There is a lot of frustration at the provider level, and it’s not unreasonable. They are overburdened, with a lot of patients counting on them and not a lot of time. Every prior authorization adds to that burden,” said Kimberly Lenz, PharmD, the clinical pharmacy manager for MassHealth Office of Clinical Affairs and an assistant professor in the Department of Family Medicine and Community Health at UMass Medical School, in Worcester. Dr. Lenz co-chairs the committee that wrote the best practices paper. “But on the flip side, managed care organizations must create formularies based on evidence. So when the AMA paper came out, the AMCP board thought it was important that our committee take the lead and spell out what we think are best practices for prior authorization in managed care.” Those best practices include:

  • taking advantage of health information technology solutions to reduce paperwork and waste, and improve the patient and clinician experience;
  • collaborating and communicating clearly with providers throughout the PA process;
  • providing advance notice of formulary changes to providers and patients;
  • avoiding broad or inflexible PA requirements for drug therapies commonly used as part of emergency care; and
  • allowing for timely PA approval for medically necessary exceptions and for timely handling of appeals of denials.

Multiple Stakeholders on Board

AMA spokesperson R.J. Mills declined to comment on the AMCP best practices, noting that “we are already well on our way to implementing an industrywide consensus on improving the prior authorization process.” In January 2017, the AMA with 16 other associations released a set of 21 principles for PA and utilization management reform. In January 2018, the AMA joined the American Hospital Association, America’s Health Insurance Plans, American Pharmacists Association, Blue Cross Blue Shield Association and Medical Group Management Association in a consensus statement on improving the PA process, which called for selective application of the PA process, regular PA review and volume adjustment, transparency and communication regarding PA and utilization management, continuity of patient care, and automation to improve transparency and efficiency.

Elizabeth Brusig, PharmD, a clinical pharmacy specialist at Optima Health Plan and co-author of the AMCP paper, said she believes that in many cases, these principles—both the AMCP’s and the AMA’s—are already being followed. “Sometimes there is a misconception that these things aren’t done. From my experience in the state I live and work in [Virginia], we have rules and regulations about such things as providing notice to members and providers about formulary changes, and then there are also accreditation standards about many of these matters as well,” Dr. Brusig said. “I still see comments to the effect that ‘bean counters’ are making these decisions rather than medical professionals, and that everything is money-driven. Yes, money is a factor, but if a drug doesn’t work or the data aren’t really there for using a particular product, it doesn’t matter how much it costs; it’s the wrong product to pick.”

Although utilization management professionals at the plan level may be focused on best practices, the reality on the ground is not always consistent with that, said Anna Hyde, the vice president of advocacy and access for the Arthritis Foundation. She was one of several experts invited by AMCP to participate in “Optimizing Prior Authorization for Appropriate Medication Selection,” a national forum featuring a wide range of experts that was held in late June.

“We know that the good practices are not in place across the board, because we have so many patient stories that suggest otherwise,” Ms. Hyde said. “When we ask patients about the issues they have with regard to medication coverage and access, prior authorization comes up as the No. 1 burden. Now, is that just that they’re encountering it the most or is it an unreasonable burden? Probably some of both. We also stay close to providers, and I can’t tell you how many times I’ve heard that rheumatology practices are having to hire additional office staff just to handle prior authorization claims. We get a lot of ‘There’s gotta be a better way’ comments.”

The national Partnership Forum was aimed at identifying that “better way,” focusing on how to:

  • improve efficiencies around PA and step therapy processes;
  • address administrative burdens, including by recommending technology solutions;
  • increase the visibility of the clinical and economic value of PA and step therapy utilization management programs;
  • collect, review and disseminate data-driven, real-world experiences of where PA programs support clinical and economic value; and
  • collect and disseminate best practices for PA appeals and denial processes.

“One of the key challenges that came up in that meeting was the need to communicate better,” Dr. Brusig said. “There are real opportunities on the horizon for technology to better aid communication around PA, to do it faster and in a more complete way that assists providers. We are seeing some progress in that field, and the ability to automate that process and use technology from end to end holds a lot of promise.”

Ms. Hyde stressed that the Arthritis Foundation does not oppose utilization management. “We recognize [there is] a place for prior authorization and step therapy; we just want guardrails in place so that patients are not unduly burdened and experiencing adverse health events.”

How should those guardrails work? “The clear message at the forum was that the people who represent plans and health systems would prefer a non-legislative solution, and our preference would also be systematic implementation of these principles at the plan level and not having to seek legislation,” Ms. Hyde said. “I think it depends on the sense of urgency for all stakeholders to follow through on these things. It’s easy to get distracted and focus on other things, so I hope the AMCP can play a role in keeping the momentum going.”

This article appeared in Gastroenterology & Endoscopy News. Read more here.