Prior authorization (PA) is at the top of national interest and debate… at the nexus of decisions we are making as an industry and society regarding what care and therapy to provide, including the most advanced care, as well as how much it should cost and how much of it patients can afford.
While many wish PA would go away altogether, that’s probably not realistic in the short to midterm because payers see PA as an effective tool for utilization management. Electronic prior authorization (ePA) is reaching an inflection point where automation will likely take some of the sting out of the process. As more data flow, the opportunity may arise for payers to reevaluate their current PA requirements so as to reduce the number of treatments requiring it. For the purposes of this article, however, the focus will be on ways to move ePA forward.
As an industry, we have made progress advancing ePA. However, its adoption beyond the pharmacy benefit for retail drugs has been minimal. As conveyed in our recent industry report, in order to move ePA adoption levels to meaningful levels for specialty and complex therapies covered under both the pharmacy and medical benefits, numerous misconceptions and gaps must be addressed. Some key areas include:
To be sure, there is much more to the ePA story than we can cover in this article. Learn more with POCP’s newly released, in-depth report on ePA. It offers health care stakeholders an independent analysis of the market, realistic maturity models and technical frameworks, a profile of what vendors and service companies are currently doing in ePA, and actionable advice and predictions so they can arm themselves with the information needed to plan strategically and meet their goals. In particular, it analyzes the use of new and transformative Da Vinci Project use cases, supported by the Centers for Medicare and Medicaid Services, built around Fast Healthcare Interoperability Resources open application program interfaces.
The report leverages our unique perspective and relationships in the market with payers, providers and their vendors. POCP experts drew on their extensive experience with ePA, ePrescribing, medication management and transactions in support of value-based care, together with industry interviews, to craft this compelling report. It’s our most extensive research report to date, with 40+ diagrams and tables, profiles of 40+ vendors in the ePA arena, and 90+ references.
To learn more about ePA and POCP consulting services, visit the POCP website or contact Jocelyn Keegan. To learn more about the ePA report or purchase it, visit its download page or contact Ken Kleinberg.