In March 2015, CoverMyMeds issued the National Adoption Scorecard for Electronic Prior Authorization (ePA). It summarizes the current state of the ePA industry, aiming to quantify current ePA adoption rates, highlight implementation status by market share leaders, and outline the keys to success for ePA in the industry. Here, two of Cardinal Health’s ePA experts – Jan Nielsen and Ben Stormer – share their perspective on ePA, why it’s needed and what steps need to be taken to implement it more broadly.
Q: What are some of the challenges posted by the traditional prior authorization process?
While well-intended, the traditional, manual prior authorization process (which typically involves phone calls and faxes between the pharmacy, prescriber and health plan) results in an enormous amount of administrative waste and can lead to high rates of prescription abandonment among patients. For example, as the recently issued ePA Scorecard indicates: Prior authorization cost the health system $728 million in 2012, according to the American Medical Association.
Q: How can automating the prior authorization help address these challenges?
By automating the process and connecting all industry participants, electronic prior authorization (ePA) can provide real-time information to support the e-prescribing and prior authorization decision-making process. Once fully implemented, ePA can benefit all players in the healthcare system by dramatically reducing administrative costs and burdens, improving efficiency and ultimately ensuring patients receive the medications they need, faster.
It’s also important to note that ePA will only grow in importance over the coming years, especially as we see an increase in specialty and biosimilar drug launches, which tend to be high-cost and are targeted at niche patient groups. Payers will likely use prior authorization as a tool to ensure these medications are only utilized to treat the right/targeted patient populations. And, because these medications will likely span both the pharma and medical benefit, we’re likely to see an increase in complexity when it comes to payer forms and process requirements.
Q: If electronic prior authorizations can drive so many benefits for the healthcare system, why is the current prior authorization process usually so manual?
Inconsistency in payer prior authorization forms and processes presents a challenge for prescribing providers. This creates variability and makes automation more difficult; although we’re hopeful that new technologies will improve automation even when variability exists.
Secondarily, the ability for those in the system to receive electronic transactions varies. Governing movements such as "meaningful use" define standards for e-prescribing and health record portability, but there are currently no enforceable standards for how payers are required to receive ePA transactions.
Q: What can be done to drive adoption of electronic prior authorization?
Electronic prior authorization vendors can drive adoption by providing open platforms and aligning on standards for transactions. Generally speaking, I think the recently issued CoverMyMeds scorecard covers several recommendations that can help drive ePA adoption:
Automating the process will be critical to expediting patient access to these medications, so they have the highest likelihood of driving optimum patient outcomes.