Optimizing Medication Prior Authorization

Problem: Prior authorizations (PAs) play a pivotal role in ensuring patients’ access to prescription medications. However, this process often leads to delays in patient care and places increased burden on healthcare professionals. Aim of the Project: The aim of this project was to expedite the processing of medication PAs for adult patients with a target of reducing the processing time to less than 36 hours. This not only facilitates prompt medication initiation for patients but also reduces costs and time expended by the healthcare organization. Review of the Evidence: A comprehensive review of the literature indicates that suboptimal PA processes can result in patient care delays, elevated healthcare expenses, and added administrative burden. Evidence showed centralizing responsibilities and utilizing electronic prior authorization (ePA) systems simplified and expedited the process. Project Design: This quality improvement (QI) project design was based on Deming’s Model for Improvement principles used to enhance patient care by standardizing processes. An inter-professional team consisting of nurses, pharmacists, and administrative staff collaborated to develop and implement a new standard workflow. Using Plan-Do-Study-Act (PDSA) cycles, the team identified key drivers of delays, which included manual data entry, fragmented communication, and a lack of standardized workflows. The OhioHealth Change Management Model was used to support the development and execution of the project and to communicate the change effectively. Intervention: The pilot intervention centralized PA tasks with a dedicated coordinator at the FQHC, utilizing electronic tools to enhance communication among the providers, pharmacies, and payers. The team conducted PDSA cycles to refine workflow standardization, PA transaction routing, and the development of a workforce coverage plan. Significant Findings/Outcomes: The project yielded substantial results, in line with existing literature. In twelve weeks, 36 PAs were processed using the centralized workflow, reducing average processing time by 79% compared to previous months. While the average time didn’t dip below 36 hours, it improved patient and staff satisfaction, and PA processing costs dropped 78%. Implications for Nursing: Efficiencies in the medication PA process significantly enhance nursing practice by reducing administrative burden and streamlining patient care, in alignment with the IOM six domains of healthcare quality. Additionally, this QI project supports the Institute for Healthcare Improvement’s Triple Aim by enhancing patient experience as nurses can devote more time to patient care instead of navigating complex, manual authorization processes

Restricted Access and Delays to HCV Treatment Among Medicaid Patients in Louisiana

Background: Many people living with chronic Hepatitis C Virus (HCV) have seen delays in accessing treatment or been denied entirely due to Medicaid restrictions requiring patients to meet certain criteria prior to receiving approval for medication pre-authorization. Methods: This study identified a cohort of Medicaid-insured patients with chronic HCV infection within New Orleans, LA. Patient medical records were reviewed and information regarding HCV care was gathered. This study sought to determine the degree to which HCV care was delayed for this population and describe common reasons for prior-authorization denials for direct-acting antiviral (DAA) medications. Results: For this population of Medicaid-insured patients with HCV RNA assay-confirmed chronic infection, the average number of days it took to reach a specialist was three-times greater than the number of days it took to reach a primary care physician. After attending an appointment with a specialist to seek HCV care, patients experienced wait periods of an average of 150 days before being deemed eligible for treatment per Medicaid requirements. After being deemed eligible for treatment, patients experienced an average wait period of 194.4 days to initiation of treatment, with low fibrosis status being cited as the most common reason for treatment delay. Conclusion: This population of Medicaid-insured patients in New Orleans, LA with chronic HCV infection experienced delays in treatment related to reduced accessibility of a specialist who was eligible to request DAA prior-authorization. Prior-authorization was most frequently denied based on low fibrosis status or recent alcohol/drug use

Prior Authorization as a Potential Support of Patient-Centered Care.

We discuss the role of prior authorization (PA) in supporting patient-centered care (PCC) by directing health system resources and thus the ability to better meet the needs of individual patients. We begin with an account of PCC as a standard that should be aimed for in patient care. In order to achieve widespread PCC, appropriate resource management is essential in a healthcare system. This brings us to PA, and we present an idealized view of PA in order to argue how at its best, it can contribute to the provision of PCC. PA is a means of cost saving and as such it has mixed success. The example of the US demonstrates how implementation of PA has increased health inequalities whereas best practice has the potential to reduce them. In contrast, systems of universal coverage, like those in Europe, may use the cost savings of PA to better address individuals' care and PCC. The conclusion we offer therefore is an optimistic one, pointing towards areas of supportive overlap between PCC and PA where usually the incongruities are most evident

Oncology trainee perceptions of the prior authorization process: A national survey

Purpose: The medical trainee perspective regarding the prior authorization process has not been previously assessed. Here we evaluate the perceptions of radiation and medical oncology trainees regarding the prior authorization process and its effect on their training and patient care. Methods and Materials: A 12-question, nonincentivized, electronic national survey of radiation and medical oncology trainees at all Accreditation Council for Graduate Medical Education accredited oncology programs was conducted. Participation, perspectives, and experiences with the prior authorization process were assessed by Likert scale, free response, and multiple response selection. Results: Between January and March of 2019, the survey was distributed to 1505 trainees at 76 institutions with responses from 174/616 radiation (28.2%) and 139/889 medical oncology trainees (15.6%). The majority (69.2%) reported participating in the prior authorization process (radiation: 78.2% vs medical: 57.6%; Conclusions: These data indicate that trainees in US oncology programs are active participants in the prior authorization process and report that prior authorization approvals negatively influence their medical training and the quality of patient care. Additional efforts to revise the insurance approval process are warranted

Medicaid and the Unconstitutional Dimensions of Prior Authorization

The political outcry over prescription drug costs has been one of the most vociferous in recent memory. From tales depicting renegade seniors sneaking cheap prescriptions of Vioxx out of Tijuana across the border, to the promises of reduced prices made by front-runners during the 2000 Presidential election, the calls for lower drug prices have been forceful and demanding. This war for lower-priced pharmaceuticals fought by consumers, interest groups and politicians against the pharmaceutical industry itself has recently developed yet another front. The latest battle is over Medicaid. The new victims are the poor. Presently, federal statutory provisions in the Medicaid program provide relief from high drug prices through a mandatory rebate mechanism. Federal law requires pharmaceutical manufacturers to rebate their drugs sold to Medicaid recipients at a minimum level of 15.1 percent of the average manufacturer\u27s price of those drugs. In addition to the mandatory rebate, federal law provides for the discretionary provision of prior authorization by which the states may serve the best interests of their Medicaid recipients in a cost-effective manner. The federal Medicaid program allows states to condition prescription of a covered drug on special prior authorization of that drug with a state official. Both the mandatory rebate and prior authorization provisions serve to balance access and cost in\u27 an attempt to provide necessary care for the indigent

Optimizing Electronic Medication Prior Authorization: Reducing Prescription Delays

Background: Within the United States, chronic disease in children has doubled over the last 20 years. Many diseases defined as chronic (attention deficit, epilepsy, and diabetes) require daily medication regimens for optimal management. To be covered by insurance, many of these medications require prior authorization (PA) from the patients’ pharmacy benefits policy. Delays in processing and receiving PA orders can lead to worsening disease and inadequate disease management. In 2014, a pediatric academic medical center in the Midwest found that processing medications from prescription order to PA approval took nurses an average of over 90 hours. In August 2020, the organization implemented an electronic prior authorization (ePA) system that interfaced with the organization’s electronic health record (EHR). The primary goals of this implementation were to reduce medication PA turnaround times and to increase employee engagement with the ePA system. The goals of this quality improvement (QI) project are to optimize the existing ePA system with the medication PA process to reduce average medication PA turnaround times and to increase the approval rates for medication PAs by five percent. Project Design: Three interventions support the outputs of this QI project. Increase the availability of the ePA system by changing the patient and pharmacy benefits insurance matching interface logic. Reduce the number of medications falsely requiring PA by removing them from the ePA system. Increase PA processing efficiency by improving the workflow for attaching documents required for PA approval. To accomplish and measure these interventions, data reports and surveys were developed to establish baselines and to measure ePA turnaround times, PA approval rates, and user satisfaction both pre- and post-intervention. User satisfaction was measured utilizing a secure online survey emailed to ambulatory division nurses. Results: The median medication ePA turnaround pre- and post-interventions was unchanged at 36 hours. The ePA approval percentage dropped from 55.7% in June 2021 to 46.9% in August 2021. The primary QI project outcomes of reducing turnaround time and increasing the approval rate by 5% were not met. A user involvement survey was sent to 194 nurses with a response rate of 29% pre intervention and 8% post intervention. Overall user satisfaction was measured using a net promotor score which registered scores of –70 pre- and –82 post-intervention, revealing overall dissatisfaction with the ePA system. The use of an alternative ePA system outside the organization’s EHR was discovered after the QI project data was reviewed and showed that roughly 45% of ePAs were completed using this alternative system during the QI project timeframe. Recommendations: User involvement surveys measure user engagement with electronic systems and measuring user satisfaction is beneficial to providing direction for interventions as well as predicting future utilization of healthcare informatics projects. Conclusion: Though most of the goals for this QI project outcome were not met, use of the alternative ePA system confirmed the Technology Acceptance Model that users prefer the electronic system that they perceive as being the most useful. Nurses using ePA will use the system that best addresses their own user experiences regarding content, accuracy, format, timeliness, ease of use, and overall satisfaction

Prior Authorizations and Addiction Treatment

Key Points Concerns about prior authorizations have grown given research demonstrating inconsistent coverage and review policies across insurers, interruptions to care, high provider burden and higher healthcare costs. Tennessee policymakers and insurers have recently taken appropriate measures to ease the concerns and minizine unnecessary barriers. TennCare changed their policy on buprenorphine allowances in May 2023, essentially removing the prior authorization barrier for buprenorphine/naloxone preferred products. This is a significant step for Tennesseans given that the research shows that once the prior authorization process was removed for medications for opioid use disorder (MOUD), patients with opioid use disorder (OUD) were 47 percent less likely to relapse, hospital and emergency use decreased, and healthcare costs decreased