Prior authorization (PA) for medications, devices and therapies is viewed as a valuable utilization management tool by payers but a long-standing pain point for providers and pharmacists. Led by the American Medical Association, a 17-member coalition — including the American Hospital Association and groups representing providers and pharmacists — recently drafted a framework for prior authorization reform based on 21 Principles. The coalition hopes the Principles will be adopted by insurance companies, pharmacy benefit managers (PBMs), those involved in utilization review and accrediting bodies.
The 21 Principles on the surface may appear to be daunting to many payers and pharmacy benefit management companies (PBMs). However, they can leverage existing health information technology (health IT) to streamline and improve PA processes to bring them in line with the coalition’s suggestions.
Most of the 21 Principles address specific coverage and process issues. However, the use of health IT can be leveraged both implicitly and explicitly to facilitate several of the Principles. Here are five examples.
Going Forward. Some readers of the 21 Principles may find parts incendiary, particularly those with perspectives that are different from the AMA and coalition. We view it as renewing a constructive dialog for figuring out how to balance patients’ needs for quick access to appropriate therapies and the needs of payers and PBMs to control costs and utilization. We applaud the work of the AMA and the coalition for getting the conversation restarted. We also acknowledge the work and foresight of NCPDP and others, which supports the infrastructure needed to make PA a totally electronic process.
So what’s next? Point of Care Partners understands the workflows and pain points involved in switching to ePA — both as national experts in the issue as well as conveners of the NCPDP task group on ePA. We suggest formation of a cross-functional group to come together as an industry to discuss challenges and opportunities. Together, we can make ePA an even better tool to get the right drug to the right patient at the right time at the right price.