IF YOU’VE PRESCRIBED a medication for ocular surface disease lately, you’ve probably been asked to complete a prior authorization (PA) to get a medication “covered.” The overarching goal of a PA is to ensure that patients receive appropriate medication while keeping health care costs in check. However, according to the 2022 American Medical Association (AMA) Prior Authorization Survey, 64% of physicians reported PAs have led to ineffective “step” treatments in their practices, often requiring additional, unnecessary office visits (AMA, 2023).

PHYSICIAN IMPACT

The process of obtaining medication PAs can create a significant administrative burden for an office. It’s been reported that physicians and their staff spend approximately 14 hours per week completing PA requests, and 88% of providers claim the PA burden on their office is high or extremely high (AMA, 2023). Obviously, an increased administrative burden has the potential to lead to decreased face-to-face time with patients, less time to interpret lab and test results, and reduced professional interactions. These are perhaps a few reasons why recent studies have found a correlation between an increase in administrative task load and physician burnout (Babbott et al, 2014; Shanafelt et al, 2016).

PATIENT IMPACT

In 2022, 94% of physicians reported that PA requirements have resulted in delayed access to necessary care, and 33% of physicians said that PAs have led to a serious adverse event for a patient in their care (AMA, 2023). When we add in the fact that approximately 406 million prescriptions are rejected each year due to PAs, we begin to understand the significant and far-reaching negative influence that PAs can have on our patients’ health care (CoverMyMeds, 2020).

When it comes to patients requiring specialty medications, the statistics are even more grim. Sixty percent report difficulty receiving their first dose of prescribed medication, and 10% report having to wait at least eight weeks for their prescription (CoverMyMeds, 2020). Pharmacy claims data indicate that when a prescription is rejected due to the need for prior authorization, patients end up with the intended medication only 30% of the time. And in 40% of cases, therapy is abandoned altogether (CoverMyMeds, 2020).

Perhaps even more concerning is that 31% of physicians report that PA criteria are rarely or never evidence-based, despite 100% of health plans stating they use peer-reviewed evidence-based studies when designing their PA programs (AHIP, 2020).

IMPROVING EFFICIENCY

Insurance companies often require documentation that a patient has failed other therapies before covering a prescribed medication. Routinely documenting current prescription and over-the-counter medications, as well as prior therapies that have been unsuccessful into the patient’s electronic health record (EHR), can be a time-saver when a PA must be initiated. Some EHR systems can also alert you when a drug is more likely to require a PA, so being familiar with alternative medications for such drugs could also help you avoid the PA process altogether, if desired. Most importantly, if you determine that a brand-name medication is necessary, document your reasoning in the patient’s care plan.

PAs can be frustrating for everyone involved. Understanding the overall PA process and their timelines, knowing medication triggers and common reasons for denial, and keeping patients in the loop as to the overall PA progress can help reduce frustrations to a manageable level. CLS

References

1. American Medical Association. AMA prior authorization (PA) physician survey. 2023. Available at https://www.ama-assn.org/system/files/prior-authorization-survey.pdf . Accessed Sep. 28, 2023.
2. Babbott S, Manwell LB, Brown R, et al. Electronic medical records and physician stress in primary care: results from the MEMO Study. J Am Med Inform Assoc. 2014 Feb;21;e100-e106.
3. Shanafelt TD, Dyrbye LN, Sinsky C, et al. Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clin Proc. 2016 Jul;91:836-848.
4. CoverMyMeds. 2020 Medication Access Report. 2020. Available at covermymeds.com/main/pdf/2020-Medication-Access-Report-Executive-Summary-Pre-Release.pdf . Accessed Sep. 28, 2023.
5. AHIP. AHIP 2022 Survey on Prior Authorization Practices and Gold Carding Experiences. 2022 Nov. 14. Available at ahip.org/resources/ahip-2022-survey-on-prior-authorization-practices-and-gold-carding-experiences . Accessed Sep. 28, 2023.