Helpful Physicians

Prior Authorization and the Impact on Physicians

During research for the Simplify Prior Authorization (SPA) white paper in 2020, we learned how the prior authorization (PA) workflow process was impacting prescribers. We heard that there are several areas that make current PA processes challenging for physicians in delivering care to their patients.

The impact of the PA workflow process on physicians is an important consideration as prior authorization is increasingly applied to the many new speciality drugs entering the market for private reimbursement. Speciality drugs being those that are $10,000 or more annually. Considering the complexities in the current workflow for PA, there is growing support from physicians and those who work with them to make the process more efficient for everyone involved.

What we heard

Physicians appear to understand the objectives and place of prior authorization in the reimbursement landscape, but they are also quick to point out that while adjudication may belong to payers, payers do not operate in isolation. For physicians, PA itself is not necessarily the issue, it is the burden of the current workflow process. Time spent on PA is time not available for patient care, and this is a contributor to physician burnout according to Reforming the Prior Authorization Process, June 2020, Medical Economics Journal.

If typical approval rates gathered during research for the PA white paper is accurate, physician prescribing is largely aligned with current payer criteria. However, there are a couple of reasons that may account for delays in patient access resulting from the time between prescribing and the time when a patient is approved by their payer for therapy:

  • It may be that the administrative process itself and not clinical criteria is causing delays, meaning the time preparing the claim for submission can be burdensome, and/or the time to sourcing and providing missing or outstanding information, and review by payers.
  • Patient history and/or past medication use, particularly when it goes back years, can be required by payers but may not be readily available to the current prescriber and may cause delays in approval. This may be repeated if the same information is required at prescription renewal.

The risk of delays in coverage decisions mean that physicians or patients may abandon preferred treatment, or pursue another, possibly less effective, course of therapy. This may result in disease progression and substantial patient anxiety during a time when they are physically and emotionally vulnerable. Either way, additional costs such as abandonment of therapy, presenteeism and absenteeism, or even hospitalization, may ultimately be borne by either the plan sponsor or the healthcare system. To our knowledge, such costs have not been measured in Canada.

What would help prescribers?

The feedback we received from prescribers is that a harmonized online solution would be ideal. To be most effective this would include an easy to navigate a system that could be accessed by multiple patient access stakeholders, who could assist in the completion of required claim fields, followed by prescriber e signatures and an e submission process directly to the payer. This would alleviate at least some physician concerns around administration and patient access timelines. If this were fully integrated with patient support, patient access and speciality pharmacy, the process would be seamless. This would mean:

  • Patient coverage and histories would be displayed in similar order and layout between payers, while recognizing that additional unique fields and criteria required by payers will exist.
  • The elimination of the duplicate fields between systems by ensuring just one data entry process to enable the transfer of common information between stakeholders who ‘touch’ the PA application.
  • The ability to resource specialists to communicate peer to peer on complex reimbursement decisions.
  • Submission of prior authorization claims electronically (ePA), including electronic signatures.
  • Ultimately allowing some claims to be adjudicated online to expedite access to appropriately prescribed specialty medication.

Patients over paperwork

In the United States, where admittedly the healthcare system is very different from ours, there have been similar challenges in the prior authorization process for physicians and there is evidence of the human and medical costs associated with PA when the workflow process is not efficient.

This evidence, and more, has initiated a “Patients Over Paperwork” effort in the U.S. to agree on strategies to thoughtfully improve the PA workflow process and reduce the administrative burden of PA. Physicians, patients, patient support programs, and payers would benefit from a similar philosophy in Canada.

As the Simplify Prior Authorization work evolves, we are considering ways the PA workflow process can be simplified to better support physicians as well as other stakeholders in the care of patients. We encourage outreach from existing stakeholders, especially payers, in this landscape as we strive to create a collaborative multi-stakeholder solution, funded by diverse stakeholders, to simplify prior authorization in Canada.

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

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