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Prior Authorization 2023: New Resources and Solutions

The Simplify Prior Authorization (SPA) initiative recently hosted its first webinar in 2023 for group benefits stakeholders on new prior authorization (PA) resources and solutions. Interest was high, with the largest registration numbers since the initiative began.

The new Simplify Prior Authorization resources for PA stakeholders was launched, OkRx provided insights into first generation electronic prior authorization (ePA), and industry leaders formed a panel to explore the future of prior authorization. If you missed it, you can view the full webinar here.

Attendee polling taken at the beginning of the webinar told us our agenda and our activities over the last year are on track:

  • 69% think there needs to be more resources about PA and assistance in understanding the process and
  • 62% told us that based on their experience of the current process it’s not fine – it needs improvement.

Over half registered for the webinar because they wanted to understand more about the current PA process, were interested in opportunities to improve the current PA process, or they wanted to hear opinions of experts in the industry about PA and its future.

Presentations/Demonstrations

Denise Balch, Project Manager for the SPA initiative introduced the new Simplify Prior Authorization website. The new site is a resource for all stakeholders in the PA process, including patients. In addition to advocacy and information on PA, the new site includes stakeholder specific education and guidance on PA, plus information on ePA, and a resources section with links to insurer PA pages, patient groups, patient support programs, specialty pharmacies, and more. In 2023 plans are underway for the development of best practices standards for PA, and to conduct an annual survey of PA stakeholders.

Ramy El-Kholi, Pharm. D., Chief Commercial Officer at OkRx addressed the challenges and solutions in the PA and ePA process. Did you know that ‘flattening’ of pdfs impedes the digital transfer of information or that the majority of online PA claim forms fail to meet Canadian accessibility standards? No surprise then that the Canadian market is preparing for ePA. Attendees saw a demonstration of the progress that has been made in an ePA solution, including completing claims information securely online and capabilities for insurers to receive claims digitally for their review.

Panelists

During our panel discussion we were fortunate enough to be joined by industry experts that represent the diversity in the PA process.

  • John Leombruno, B.Sc.Pharm., Master of Business Administration (MBA), Doctor of Philosophy (PhD), President and CEO, OkRx
  • Dr. Alan Low, BSc. (Pharm.), Pharm.D., RPh, ACPR, FCSHP, CCD, Clinical Associate Professor, University of British Columbia
  • Rachael Manion, J.D., Executive Director, Canadian Skin Patient Alliance
  • Ned Pojskic, PhD, Vice President, Pharmacy Benefits Management, Green Shield
  • Joan Weir, President, Group Benefits, The Canadian Life and Health Insurance Association (CLHIA)

Panel discussions focussed on the opportunity and potential for adoption of ePA in the private sector, which although now available, will take time to adopt. National standards and benchmarking, voluntary or possibly legislated, can improve transparency in the current private payer PA process which will be beneficial for stakeholders, particularly patients.

Here are some more details:

  • Insurers and Prior Authorization – “If we look into the future, ePA will be the solution. The only unknown is how long it takes to get there, and what the path is to get there.” – John Leombruno
    • Modernization at the insurer level is starting to get more traction, but it’s still in its early days.
    • A move to ePA requires national standards. Implementing regulatory infrastructure or governance around insurer prior authorization can help drive further development in an ePA future. Once we have standards as a country then we can leverage those standards across all providers.
  • Coordinating private and public ePA systems – “I see it working [through] leading by example – have some things in place, where you’ve got maybe some of the roads built, and then somebody might build the highway that will connect them all” – Dr. Alan Low
    • Ontario and British Columbia both have public ePA systems now.
    • To align and get all providers in both private and public systems together through an ePA solution will be challenging. Legislation and national standards can help.
    • Electronic Medical Records (EMR), and the many solutions available, is an example of how difficult it can be to implement systems that are accessible and consistent for stakeholders in both the public and private sectors.
  • What more can we do to help patients in the PA process?
    • An ePA solution has the capacity to address the main concerns in the PA process for patients around timeliness issues and reducing unnecessary delays.
    • Benchmarking standards and best practice recommendations can help with transparency and would be beneficial for many patients. For example, every insurer delivers information about denied claims differently at within a different timeframe. This can impact patient access to the medication they need.
    • The criteria for prior authorization in the public sector is more often shaped by the incorporation of patient voice, patient input, and clinician input based on the lived experiences of patients than among private payers.

The Bottom Line

Attendee evaluations are always informative, and when we ask for the top three takeaways we are sometimes surprised, but not this time. Here is a summary of the top three takeaways from the webinar’s attendee evaluations:

  1. The PA process is complex, frustrating, and confusing – especially for patients.
  2. PA involves many different stakeholders and requires collaborative effort to evolve.
  3. There is a lot of work to be done on PA and ePA provides an opportunity to improve it.
  4. Get Involved

The SPA initiative and its partners are advocating for improvements in the PA process and the greater access to information on PA for all stakeholders. We believe this can happen with the adoption of an agnostic and seamless, electronic process for completion and submission of PA claims as a first generation ePA solution, and through stakeholder resources like the Simplify Prior Authorization website to improve the transparency of the process.

There is more work to do before to improve PA and create a better understanding of the process. You and your organization are invited to the table to work collaboratively towards constructive change.

For more information on Simplify Prior Authorization, to get involved, or to support this initiative you can contact Denise Balch at info@simplifypriorauth.ca or 905 220 4260.

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