Every January, we publish our take on trends that will influence health information technology (health IT) in the coming year. For 2019, we are leaving it to others to prognosticate on the big ones, such as interoperability. Instead, we are taking a deeper dive into three areas where we see significant numbers of activities that will affect health IT in both the short and long term: electronic prior authorization (ePA), specialty pharmacy automation and value-based care.
ePrior Authorization to Improve Medication Access
A growing number of medications require prior authorization (PA) before they can be dispensed. This is causing friction among providers, who are very concerned about the impact. In response, the industry has ramped up an electronic process to make PA submissions and responses faster and easier, prevent delays in treatment and find affordable therapies. Although the industry has been working on this since passage of the Health Insurance Portability and Accountability Act (HIPAA) in 1996, not much progress has been made. That should change in 2019. Here are six predictions for ePA:
- 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.
- 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).
- 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.
- 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.
- 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.
- 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.)
Specialty Pharmacy Automation Will Improve Speed to Therapy
Specialty medications are high-cost, complex drugs with special handling and delivery requirements. They are primarily used to treat rare or chronic conditions. While retail pharmacies are highly computerized and most noncontrolled substances are prescribed electronically, specialty pharmacy has lagged behind and is ripe for automation. Specialty medications are generally still being prescribed using antiquated paper-phone-fax methods. This results in significant delays in getting needed medication to the patient. The speed-to-therapy lag is a major pain point for both patients and providers, which also has implications for the quality and safety of care. Here are four predictions for specialty:
- Automated methods for enrolling patients in specialty programs will emerge. NCPDP will draft a standard to automate patient enrollment forms, and other proprietary methods will emerge. This component of specialty pharmacy is key to ensuring that patients start off on the right foot and provide the payer and provider with the information needed to process and dispense/administer a specialty medication. Key stakeholders and standards development organizations are stepping up to make this happen.
- Stakeholders will accelerate automating various facets of specialty prescribing, such as patient outcomes reporting and requirements associated with Risk Evaluation and Mitigation Strategies (REMS). The Food and Drug Administration (FDA) requires REMS for specific high-risk medications. They include complex processes for educating patients and physicians about a drug’s safety and various criteria prescribers must meet to ensure safe use, such as physician certification in order to prescribe the drug, patient enrollment in a central registry and restricted distribution of the drug to certain specialty pharmacies. Assessments and reports must be done periodically and provided to the FDA and the drug’s manufacturer. Currently, this involves time-consuming, labor-intensive, paper-phone-fax based processes, which are ripe for automation.
- The industry will finally grapple with solutions to definitively identify who owns coverage for a patient at the point of prescribing. Currently, prescription drugs may be covered under the patient’s pharmacy benefit, medical benefit or both. This also has implications concerning which pharmacy may fill the order. The lack of clarity results in frustration and expands time to therapy, which has implications for patient safety and quality of care.
- A baseline study of speed to therapy will be conducted. Key stakeholders who understand specialty prescribing will conduct a definitive, scientific baseline study of the speed-to-therapy lags associated with specialty prescribing. It will measure timeframes for prescribing, processing and receipt of medications as well as target areas for improvement.
Value-Based Care Solutions Will Become Available in EHRs
How we pay for health care is undergoing a disruptive, fundamental shift. We rapidly are moving away from the traditional fee-for-service, pay-for-volume approach to one that pays for demonstrated value. EHRs and automated processes are the tools powering this change. Here are four predictions for value-based care.
- The industry will double down on real-world solutions to help patients understand the true costs of their therapies. The RTPBC is a start by exposing many facets of a therapy’s actual costs to the provider and patient.
- EHRs will increase availability of clinical decision support to better merge patient orders against real-world options. This will help the physician make the proper choice for the appropriate patient at the correct time, thus improving speed to therapy and quality of care. It also will tell the clinician what documentation is needed, which will expedite the reimbursement process.
- There will be an acceleration of efforts to shift the collection of quality-related information needed for value-based care into provider workflows in EHRs. Ensuring that information is captured in workflow will be one way the industry will focus on reducing burden. Another will be continued collaboration to ensure that better measurement is integrated and automated (prospective) for providers and payers powered by collaborations, like Da Vinci, funding Data Exchange for Quality Measures. Moving from large structured documents to discrete data points using Fast Healthcare Interoperability Resources (FHIR) will reduce work and increase trust in provider-sourced content for such issues as data provenance.
- Payers will unleash patient health records, which will give clinicians a fuller picture of their patients’ health and treatments across providers and sites of care. Health plan records are an untapped silo of valuable information, the availability of which can improve care and outcomes by creating a more complete picture of a patient’s care across all care providers. Work began in earnest in fall 2018 to begin to unleash payer claims and clinical data to care providers via eHealth record exchange.
Looking Ahead. Standards development and multi-stakeholder initiatives are key to advancing ePA, RTPBC, real-time medical benefit check and value-based care. NCPDP is actively working to refine and develop standards to advance widespread industry adoption of ePA and RTPBC while Health Level 7, through the Da Vinci Project, is actively rolling out use cases in support of value-based care data exchange. An example is Coverage Requirements Discovery, for which an implementation guide will be published Q419. This use case will enable providers with a FHIR-based application program interface to discover in real time specific payer requirements that may affect the ability to have certain services or devices covered by the responsible payer.
Conclusion. The Point-of-Care Partners team is actively engaged in all of these areas. What we have reported is a drop in the bucket compared to what is planned, what is in progress and what is to come. Want to know more or become involved? Reach out to me at firstname.lastname@example.org.