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Doctor talking to pharmaceutical sales representative, shaking hands
Doctor talking to pharmaceutical sales representative, shaking hands

Canada vs U.S. Prior Authorization Trends: The Role of Transparency and Communication in Prior Authorization

In our last blog we summarized the prior authorization (PA) reform experience in the United States, including the role of the 2018 American Consensus Statement, which was developed through a collaboration between several healthcare associations. The Statement identified opportunities to improve the PA experience.

One of the five areas of improvement identified in the Statement was in payer Transparency and Communication. This was based on the belief that with effective communication channels between stakeholders PA claims can be submitted with the complete information necessary for payers to make a decision as early as possible in the process. To facilitate this, the Statement recommended the following be in place:

  1. Clear articulation and easy accessibility of PA requirements, criteria (unlikely in Canada), rationale, and program changes to health care providers and patients
  2. Timely resolution of PA requests to minimize care delays
  3. Timely notification of PA decisions by health plans to impacted health care providers (physicians and dispensing pharmacists), and patients.

Why Transparency Matters

Transparency, or clarity, from payers on the PA workflow process is beneficial for several reasons:

  1. Efficiency: Clear process requirements reduce the back-and-forth communication between healthcare providers and insurers.
  2. Administrative Costs: Higher rates of complete and accurate first time claim submissions will relieve the administrative cost pressures of PA.
  3. Patient Care: Patients are best served when physicians and patient support understand claims requirements and processes and can work together to meet them.
  4. Managing Expectations: When both payers and healthcare providers are working from clear and common processes, expectations are managed, and stakeholders believe they are being treated fairly.

The Workplace Safety and Insurance Board (WSIB) in Ontario, offers an example of what transparency can look like to prescribers and their patients in Canada. The WSIB site lists what prescribers must include in the application for a prior authorization drug, including but not limited to the rationale for requesting the drug, dose and duration of treatment, laboratory results, and supporting literature. Canadian private payers may choose not to make this level of detail readily available. However providing a thorough list of requirements for claims evaluation can provide clarity to other stakeholders that will reduce frustration, and improve the timeliness and efficiency of the process, avoiding lengthy delays for additional or outstanding information.

Why Adopt Canadian Workflow Standards

All stakeholders in the private benefit landscape in Canada would benefit from common industry workflow standards. According to the Standards Council of Canada, a standard is document that provides a set of agreed-upon rules, guidelines or characteristics for activities or their results. Standards can establish accepted practices, and have benefits not only to protect consumers, but also by promoting competitiveness and facilitating innovation.

(Reference: https://www.scc.ca/en/standards/what-are-standards)

The Best Practice Standards for Prior Authorization in Canada are now in development, led by the Simplify Prior Authorization initiative, and supported by a diverse group of stakeholders.

Thank you to Gold sponsors of the SPA initiative Amgen and Gilead, plus Silver sponsors AstraZeneca and Cencora/Innomar Strategies.

Look out for the next in our blog series on Canada vs U.S. prior authorization trends, an update on the development of the first Canadian Prior Authorization Best Practice Standards, and upcoming webinars on developments in prior authorization for your industry sector.

Stakeholders with an interest in prior authorization are invited to reach out to SPA to contribute to the development of these Guidelines.

If you would like to know more about this initiative, are interested in getting involved or sponsoring this initiative, please contact Denise Balch at info@simplifypriorauth.ca.

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Our LinkedIn Page provides useful resources and information related to Prior Authorization with resources available for patients, benefits and healthcare stakeholders, follow our LinkedIn Page to stay up to date.

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