Discussing Electronic Prior Authorizations

Poor medication adherence or non-adherence limits the ability of physicians to manage and control chronic illnesses, makes it difficult to prevent diseases, increases hospital, doctor, and emergency visits, and can greatly increase costs when managing serious and chronic illnesses.

Prior Authorization (PA) is an approval requirement that must be obtained from a health insurance plan before a particular medication is covered. This can be time consuming for physicians as they very often spend 16-20 hours per week working through requests to provide clinical clarification for a PA coverage determination.

This process can be handled much more rapidly by using Electronic Prior Authorization (ePA) since ePA automates many of the communications among healthcare providers, payers, and pharmacists which in turn, helps patients obtain their prescribed therapies without delay.

Joel White Director of “Health IT Now” https://www.healthitnow.org, a broad-based coalition focused on improving healthcare through data and health IT, discussed the promise of ePA and the need to move forward with the technology at a briefing held on Capitol Hill on April 26, 2018.

He stressed the need for the use of ePA so more doctors and patients will be able to deal with a streamlined system to be able to authorize prescriptions sooner without the patient facing additional issues concerning their medications.

Speaking at the briefing, Congressman David Schweikert (R-AZ) along with the House Ways and Means Committee members Congressmen Bill Johnson, Mike Thompson, and Ben Ray Lujan introduced the bill titled, “Standardizing Electronic Prior Authorization for Safe Prescribing Act of 2018” (H.R 4841) in January.

As Congressman Schweikert explained, “This bill will make a significant difference in ePA usage in the Medicare Part D Program and at the same time, greatly improve an outdated system and standardize the PA process.”

He continued to say “We have a changing society so we can’t slow down healthcare technology. We need to embrace the concept of ePA because it will greatly affect not only the millions of baby boomers that are already on Medicare but also the millions of baby boomers that will be signing up for Medicare in the coming years.”

Perry Lewis Vice President of Industry Relations for CoverMyMeds https://www.covermymeds.com, a company that helps providers and patients adopt ePA. His organization’s hope is that the ePA legislation moves forward.

He pointed out that ePA can be initiated within the workflow, can be tracked electronically, reduces duplication of efforts, expedites therapy for the patient, and reduces healthcare and administrative costs.

He and others conclude that using ePA would increase speed to therapy, have a positive impact on patients and providers, and make it less likely that patients having difficulties obtaining their medications may just abandon getting prescriptions at all.

National Adoption Scorecard http://epascorecard.covermymeds.com is  published each year by CoverMyMeds along with advice from an advisory board of industry experts. This year, additional new data elements and ePA updates have been added to the Scorecard.

The Scorecard now provides information on real-time prescription benefits plus effective solutions for obtaining specialty medications. Plus, the Scorecard provides up-to-date information on individual state mandates around PA and any federal movement involving PA.

Sumner Madden Senior Director AstraZeneca Access 360 Team https://www.astrazeneca.com discussed, how his organization understands how financial and administrative barriers can be frustrating to both providers and patients. Plus it can take even more time for providers to complete the medication authorization process especially with oncology and asthma patients and can result in patients waiting three to six weeks for medications.

As he explained, “AstraZeneca’s “360 Access Patient Support Program” is staffed by experienced patient access specialists. The staff helps patients and providers navigate coverage and administrative challenges and also connects individuals to affordable programs.

Representing ophthalmologists, Catherine Grealy Cohn, Vice President for Governmental Affairs for the American Academy of Ophthalmology https://www.aao.org reports that the Academy has heard from many retina specialists that some Medicare Advantage (MA) plans are requiring prior authorization for each intravitreal injection received to treat AMD, a chronic condition that requires monthly treatments. The Academy plus other physician specialty societies are advocating for legislative and regulatory changes related to how MA plans use PA.

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