Pharmacists and the prescription prior authorization process
Friday, April 14, 2017
Pharmacists working in the community pharmacy setting know the situation all too well. A patient brings in a prescription for a new medication. He has had a discussion with his doctor about the drug and decided he is willing to try something new. But then he is disappointed and confused to be told that the prescription requires something called a "prior authorization."
The doctor, patient and pharmacy have all invested some time into this decision and this prescription, only to be denied the ability to fill it.
The next step for many pharmacies is to contact the prescriber's office and let them know it cannot be filled. But some pharmacies will attempt to take it a step further and reach out to the PBM or insurance company to obtain the necessary prior authorization forms. This step allows the pharmacy to help get the process started, potentially shortening the wait time for the patient.
But more commonly these days, the health plan rejects such efforts and requires the physician's office to call themselves. I've even been told by some plans that the pharmacy cannot even request the PA form be faxed to the M.D.
Why? Why are pharmacies and pharmacists, which are supposed to help manage the medication needs of their patients, being excluded from taking part in this process?
Well, of course, the simple answer is money. Health plans want providers and their offices to feel every bit of the pain involved in these extra steps, as a mechanism to discourage writing for these more expensive medications.
Studies suggest the prior authorization process is very costly to physician practices, upwards of $70,000 per physician per year. These costs are related to the additional time spent by office staff to answer questions, interact with health plans and complete paperwork related to these approvals.
Of course, the PBM doesn't seem to care if their processes cost healthcare providers more time and money, as long as their own costs go down. But what they save in prescriptions may end up costing the health plans more down the road.
"Prior authorization can be penny-wise and pound-foolish," Loretta Bush, CEO of the Michigan Primary Care Association, told The Detroit News in March. "The process might save money up front, but patients who are denied their doctor's first choice of medication may end up getting sicker."
I've seen it firsthand in a hospital setting where a patient is denied an outpatient antibiotic, so the patient is kept longer in the hospital as a result. This type of thing happens all the time, and health plans don't seem to notice that the PBM that is supposedly saving them money is laughing all the way to the bank.
Allowing pharmacies to get more involved in the prior authorization process could help coordinate the efforts of providers with patients and pharmacies. A pharmacist was probably involved in developing the prior authorization criteria at the health plan, so why shouldn't a pharmacist be involved in assessing patients for whether they are an appropriate candidate for the therapy recommended by the physician?
Some pharmacies, of course, won't want anything to do with the extra work involved. Also, there may be a learning curve for some pharmacists to get used to researching and reviewing criteria documents published by managed care plans.
But the results can be a stronger relationship with both providers and patients, and approved medications will typically result in higher revenues for the pharmacy to compensate for the added time and effort. Online tools like formulary search engines, plan websites and published criteria documents will become valuable resources. In some cases, pharmacies will also need to become familiar with the financial assistance resources available for patients with high co-pays.
Overall, it is my strong, personal opinion that pharmacies should be allowed to fully engage in the prior authorization process of prescription medications, working closely with the physician office staff, patients and payers to create a more integrated system that benefits patients. While the process can be time consuming, it can also be both rewarding and financially viable.
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