Solutions Are Emerging to Help MIDs Efficiently Manage Prior Authorizations

Payers use prior authorization (PA) as a utilization management tool and costcontrol process to ensure medical necessity, requiring physicians to seek prior approval to qualify certain services for payment. Unfortunately, PAs can place a huge administrative burden on physicians and practices. This is especially true in oncology, as the rising cost of new cancer drugs brings intense scrutiny from payers.

Medically integrated dispensing (MID) pharmacies in oncology often deal with complex PAs that can inhibit delivery of timely, quality care and consume staff resources. Consequently, oncology practices with MIDs often seek more efficient ways of handling PAs. Fortunately, new innovative consulting services are emerging that can enable oncology MIDs to manage PAs more efficiently. A close look at one of these services, as well as an examination of the difficulties PAs can cause, may provide understanding of how this type of solution can create efficiencies in MID operations.

PAs Can Inhibit Quality Care

Although health care technologies available today enable practices to run more processes automatically, much of the PA process in oncology MIDs is still performed manually, creating barriers that can delay care. Such delays can be detrimental to patients. Increased anxiety, diminished quality of life, and suboptimal outcomes may occur when the start of treatment is postponed or ongoing care is interrupted.¹

A 2021 American Medical Association (AMA) physician survey about PAs² highlights how often the process negatively affects treatment. Of 1004 practicing physicians responding to the survey, 93% reported the PA process delays access to necessary care. Additionally, 82% reported the process can lead to patients abandoning their recommended course of treatment. Significant patient harm caused by PAs is also called out in the survey²:

• PAs have led to a serious adverse event (AE) for a patient, according to 34% of physicians.
• PAs have led to a patient’s hospitalization, according to 24% of physicians.
• PAs have been linked to life-threatening events or the need for intervention to prevent permanent impairment or damage, according to 18% of physicians.
• PAs have led to a patient’s disability, permanent bodily damage, congenital anomaly, birth defect, or death, according to 8% of physicians.

For patients whose treatment requires PA, 91% of physician respondents say the process has a somewhat or significant negative impact on the patient’s clinical outcome.²

Negative Impact

Payers top the list of stressors confronting oncologists, with PA the most cited source of stress.³ The hassles and delays caused by PAs often weigh heavily on oncologists as their patients wait for therapies pending PA approval.

According to the AMA survey, the PA process can place an additional administrative load on practices, with 88% of physicians describing the “burden associated with Pas as high or extremely high.”² On average, practices complete 41 PAs per physician per week, and physicians and their staff spend 13 hours each week completing PAs.² Forty percent of physicians in the survey indicate they have staff who work exclusively on PAs.²

PAs Create Time-consuming Obstacles

The integration of pharmacies into oncology practices is a growing trend. For instance, from 2010 to 2019, the percentage of oncologists in practices with MIDs more than doubled, from 12.8% to 32.1%.⁴

Not only do MIDs provide an additional revenue stream for the practice, but they also can significantly enhance cancer care. First, because the prescribed drug is dispensed from the provider's office in a timely manner, the patient can begin therapy as soon as possible. This is extremely important for patients, especially those dealing with aggressive cancers. When treatment is delayed, outcomes and quality of life can be affected. Additionally, staff can support adherence and optimal outcomes by educating patients on prevention of AEs, and by managing AEs as well.

However, these important benefi ts can only be fully realized when MIDs are operating efficiently. In busy oncology practices, the goal is for the MID to promptly process and fill a prescription once it is received. Whenever a PA is involved in the flow of the prescription, however, difficulties can arise, as the PA process is often complex. Multiple phone calls, faxes, emails, and contacts with a payer often are required. Some payers have long hold times and backlogs that stall progress.

Empowering MIDs to Overcome PA Challenges

Service offerings specializing in the complex PA process have begun to emerge, with the goal of enhancing efficiency and productivity. McKesson provides one such solution, ScriptPAS, designed to enable MIDs to navigate the PA process quickly and efficiently, facilitating timely access to care.

ScriptPAS is a fee-for-service-based solution, much like an à la carte menu. Practices can request assistance in all 3 areas—benefits investigation, PA, and financial assistance—or simply choose whichever service they may need. Once all the requested services are completed, Script-PAS returns the prescription to the MID for fulfillment. The process takes 1 to 2 days, significantly below the industry average of 5 to 6 days.

The program is intended to remove the administrative burden from practices and patients by managing key services, including benefi ts investigation and PA.T hen ScriptPAS receives a prescription from a MID, the ScriptPAS team begins with a benefits investigation to identify the patients coverage. The payer is contacted either through an electronic channel, phone call, or fax. If this contact reveals that a PA is required, the ScriptPAS team begins work on that process. ScriptPAS maintains an extensive database documenting various payers' PA processes, including points of contact and average times for approval. If the PA is not approved, the staff communicates with the payer to identify the reasons for the denial and promptly shares that information with the MID and provider. Collaboration and ongoing communicationwith MIDs and payers help the ScriptPAS staff operate more efficiently and reduce the time to the first fill.

These results have been observed by several MIDs leveraging the ScriptPAS program, including Rocky Mountain Cancer Centers (RMCC), a practice in The e US Oncology Network that provides comprehensive care at 19 locations across Colorado. At the onset of the ScriptPAS engagement, RMCC's MID pharmacy team supported 13 sites and was consistently busy. Team members were often challenged by PAs for select prescriptions that took longer than others and disrupted workflow. Over the course of 3 months, 78% of prescriptions sent to ScriptPAS were returned to RMCC for fulfillment with an average turnaround time of 1.5 days, greatly reducing the time to first fill, which was previously 5.8 days.

Practices Gain Many Benefits

By leveraging these outside service offerings, MIDs using services like ScriptPAS allow practices to navigate the PA process more quicklyfor patients and potentially increase prescription capture rate, generating more revenue by stopping the leakage of prescriptions dispensed outside of the MID. For instance, RMCC ScriptPAS was able to stop the leakage of more than $27,000 in prescriptions from the practice.

Large and small practices developing MIDs have much to gain from service offerings like this. When implementing a new MID, the emphasis should be on patient care, not on administrative processes like PAs. Any size practice can gain important efficiencies with service offerings like these.

PAs Are Not Going Away

The delays caused by PAs can be distressing to practices and physicians, as well as to patients, loved ones, and caregivers who are anxiously waiting for much-needed therapies. Given the rising cost of health care, the complexity of the PA process will likely increase. This is especially true in oncology, where drug costs continue to escalate.

Oncology practices can meet this challenge by engaging innovative new services, like ScriptPAS, to explore efficiencies and stop the leakage of prescriptions to outside pharmacies. As the health care landscape evolves and presents difficult challenges to providers, more of these flexible, cost-efficient solutions will be needed.

_REFERENCES:

_{1. 2019 quality care: cost of treatment, prior authorization of treatment plans may cause barriers to care. The ASCO Post. September 3, 2019. Updated October 1, 2019. Accessed online September 13, 2022. h. ps://bit.ly/3J87NJe}

_{2. 2021 AMA prior authorization (PA) physician survey. American Medical Association. Accessed September 13, 2022. h. ps://bit.ly/3J9nccy}

_{3. Hertler A. A redesigned prior authorization is needed in oncology. Here’s how. Managed Healthcare Executive®. Published online February 9, 2021. Accessed September 13, 2022. h. p://bit.ly/3XSGnvk}

_{4. Lawrence L. Medically integrated dispensing on the rise in US oncology practices. Cancer Therapy Advisor. July 25, 2022. Accessed online September 14, 2022. h. p://bit.ly/3HoYzXI}