Prior authorization (PA) for medications, devices and services is viewed as a valuable utilization management tool by payers but is a long-standing pain point for providers, pharmacists and the pharmaceutical industry. A 17-member coalition of powerful stakeholders — led by the American Medical Association (AMA) — recently drafted a reform proposal based on 21 Principles.
Why should pharmaceutical companies care? On first blush, the 21 Principles seem focused on payers. However, pharmaceutical companies should look again. If implemented — and we believe they will be — the 21 Principles will significantly affect the accuracy and transparency of how medications are prescribed and reimbursed. Their adoption also will have a profound and sustained impact on the use of electronic health records (EHRs), utilization management, prior authorization and related provider workflows. For example, their adoption could:
First, a very powerful stakeholder group developed the 21 Principles, which will give them traction among policymakers. As a result, many (or all) of the 21 Principles could end up being mandated through regulation, either Federally or at a state level. This will give EHR vendors further impetus to make critical upgrades so their systems accept transactions using the ePA standard from the National Council for Prescription Drug Programs (NCPDP), as described in Principle #12. NCPDP’s ePA standard enables up-front prior authorization during electronic prescribing from an EHR. This is quicker and more efficient than the current “retrospective” process. Retrospective PA is disruptive to workflows, time consuming and often results in patients going without medications or getting a different therapy than what was originally ordered. Moving to ePA benefits practices and the pharmaceutical industry by creating more time for providers to spend with patients and less time on administrative duties.
Going forward. Point-of-Care Partners (POCP) applauds the work of the AMA and the coalition for getting the conversation restarted on how to balance patients’ needs for quick access to appropriate therapies and the needs of payers and pharmacy benefit managers to control costs and utilization. We also acknowledge the work and foresight of NCPDP and others, which supports the infrastructure needed to make PA a totally electronic process.
POCP also 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. Let us know how we can put our expertise to work for you.