Dr checklist with a patient

Prior Authorization: The Impact On Patients

During research for the Simplify Prior Authorization (SPA) white paper in 2020, we learned how the prior authorization (PA) process was impacting patients. We heard that there are several areas that make current PA processes challenging for patients and those working on their behalf. This is an important consideration as the utilization of prior authorization evolves, and we collectively work to make the process more efficient for everyone, particularly patients. Here are some of the issues SPA will address.

Defining the circle of care

Some patients are required to be on the phone for the payer (insurers or PBMs) to release claims information or claim status to the patient’s drug access navigators (DANs) or pharmacist. This makes it challenging for them to work efficiently on behalf of the patient and places an added burden on the patient who is often either newly diagnosed or coping long term with a chronic and life changing diagnosis. During such a complex process, a simple authorization by the patient would address this.

Public-private parameters

For some claims, payers require a rejection letter from the public payer before they will consider coverage, even in cases where the public payer has never funded that drug for the prescriber’s intended use. This type of process barrier could be managed more efficiently directly between public and private payers.

Track and trace

Patient treatment schedules can be impacted by a lack of transparency about where a PA claim is in the approval process, which can result in the cancellation of drug administration appointments and delays in treatment. Delays can inadvertently lead to disease progression at untold patient expense. Where prior authorization is required, an initial response indicating consideration for approval (or not) would allow physicians or navigators to choose other options. A transparent process to track the claim request would avoid repeated calls into insurers for approval status updates.

Requirements for coverage consideration

In some therapeutic areas, like oncology (cancer), we were told that coverage approvals can be “all over the place” when a physician is prescribing a drug off label. Some insurers will consider PA reimbursement for off label prescribing and some will not. Using a drug off label does not mean the drug is unsafe, it means Health Canada has not approved the drug for the intended use. Physicians and insurers often rely on current clinical trials for drugs being considered for off-label use to make prescribing and reimbursement decisions. Patients and those supporting them would benefit from a more transparent, streamlined, and consistent approach to information requests based on current clinical trial work and best practices.

We can do better

The goal of our benefit plans is to support plan members facing difficult health challenges, and one of the areas of greatest need is in prior authorization, an area where the benefits industry can do much better to make the patient’s journey, and those that assist them, as smooth and efficient as possible.

We can and we must do better. When we do, we all benefit.

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