Electronic prior authorization: The solution to physicians' headaches?

Are you tired of dealing with health plans’ prior authorization requirements for certain prescription drugs? If so, you have a lot of company. But you and your colleagues may soon have the opportunity to reduce this burden on your practices and increase patient satisfaction at the same time.

It’s not that health insurers have suddenly decided they don’t need to pre-approve coverage of these medications. 

What has happened is that two technology companies, Surescripts and DrFirst, have begun rolling out solutions that embed electronic prior authorization (ePA) in the e-prescribing process. According to the companies, this

approach will allow physicians and their staffs to request approval from pharmacy benefit managers (PBM

s) and health plans inside their electronic health records. Surescripts says that practices may receive electronic responses within minutes in many cases.

Consultants and physicians say this approach not only could reduce the work and cost involved in prior authorizations, but should also make patients happier. Instead of being forced to wait a day or two for a pre-authorization to arrive, usually after an unsuccessful trip to the pharmacy, patients may be able to get a prescription approved leaving the physician’s office. At the least, notes Miami gastroenterologist James Leavitt, MD, physicians will be able to find out which drugs require prior authorization and inform patients about that in advance.

READ: Curing the prior authorization headache

Going to the pharmacy and discovering that a medication needs pre-approval, he says, “is a huge patient dis-satisfier. So from the patient’s point of view, this will be much better. It will set their expectations, because they’ll know what’s going on.”

David Boles, DO, a family physician in Clarksville, Tenn., likes the idea of having prescriptions approved while the patient is still in the office. “That would be awesome,” he says, adding that it’s about time. “It’s amazing how long this has taken.”

NEXT PAGE: Which solutions are emerging?

Two distinct  ePA solutions have been developed by companies that are well known in healthcare.

Surescripts, the firm that connects physician offices online to pharmacies for e-prescribing, is offering an end-to-end electronic service, CompletEPA, that links practices to four PBMs, including CVS/Caremark and Express Scripts. According to Surescripts, these four PBMs have contracts from health insurers to administer the drug benefits for 210 million people. All of these health plan members would potentially be eligible for ePA.

Surescripts is using a new ePA standard from the National Council for Prescription Drug Programs (NCPDP). In

the year since it was adopted, says David Yakimischak, executive vice president/general manager of medication services for Surescripts, “We’ve gotten commitments from both PBMs and physician EMR [electronic medical record] vendors to use the NCPDP standard.”

Cameron Deemers, president and chief executive officer of DrFirst, which sells e-prescribing software and has imbedded its solutions in nearly 300 different EHRs, applauds Surescripts’ all-electronic initiative. But he points out that many health plan and PBM information systems are not yet ready to accept NCPDP-based prior auth transactions.

“We’re trying to provide a universal solution so a doctor doesn’t have to go through two or three different workflows, doing some prior auths electronically, some by fax, and some by phone. We’re trying to get away from that and provide a consistent user experience for prior authorization.” 

DrFirst’s EPA solution, Patient Advisor ePA +, uses the hybrid service of CoverMyMeds to connect practices with payers. CoverMyMeds allows physicians to submit prior auth requests electronically, then sends those requests to payers in whatever form is acceptable to them, including by fax and online using the NCPDP standard.  DrFirst is also integrating other ePA services, including Surescripts’ CompletEPA, and it will connect practices directly with some health plans and PBMs. 

“Surescripts has a piece of the market, and CoverMyMeds has some kind of connection to every payer in the country,” notes Deemers. “We want to give the doctor the ability to do electronic prior auth no matter what, and that means we have to have multiple sources available.”

NEXT PAGE: Getting EHR vendors on board

For ePA to become viable, it must be available in electronic health records (EHRs) as part of the clinical workflow.

DrFirst is including Patient Advisor ePA + in the EHRs of all its vendor customers, which include Greenway, GE Centricity, LSS (part of Meditech), and Healthland, as well as several  smaller companies. It upgraded about half of these products in October and will add the ePA solution to the other EHRs later, Deemers says. DrFirst is also including Patient Advisor ePA+ in its standalone e-prescribing programs.

Surescripts scored a big win recently when Epic Systems, the largest EHR vendor, agreed to incorporate CompletEPA in its EHR. An Epic spokesman tells Medical Economics that this will happen in the first quarter of the year. Surescripts also has  signed deals with several small vendors, and Yakimischak forecasts that other leading vendors will soon follow Epic’s lead.

Other observers agree that ePA, if it works as advertised, is likely to sweep the industry because practices will demand it. In fact, ePA is the top priority of physicians in regard to e-prescribing, according to Yakimischak.

Currently, some PBMs allow practices to use their websites to make prior auth requests. But that’s outside the EHR workflow and is a manual process requiring completion of prior auth forms online, notes Cindy Dunn,  RN, FACMPE, a health IT consultant for the Medical Group Management Association (MGMA).

ePA, in contrast, takes place in the EHR and is partly automated. As described by Surescripts, the ePA software can pull data from the EHR to pre-populate patient demographic information on the prior auth form. The PBMs, via Surescripts’ benefits and formulary feature, can supply the patient’s drug coverage and the plan’s prior auth requirements. And the NCPDP standard automatically tailors the questions on each prior auth form to the patient’s demographics, skipping the irrelevant ones. 

All of this speeds up the request process, says Yakimischak. In a pilot of ePA with CVS prior to the NCPDP standard being adopted, he adds, it took only about five minutes, on average, for practices to fill out prior auth forms.

Rosemarie Nelson, an MGMA consultant in Syracuse, New York and a Medical Economics editorial consultant, questions  how practices would adapt their workflow to ePA. She wonders whether some physicians would choose to wait for a response to an online prior auth request, lengthening the patient visit. But she notes that if the approval didn’t come right away, physicians could wrap up the exam and delegate the task to their nurses. She and Dunn predict that practices will welcome ePA, regardless.

NEXT PAGE: The benefits of electronic prior authorization

Currently, practices spend a lot of time and money on prior authorization of all kinds, including the pre-approval of prescriptions.

According to a 2009 study, prior auth takes up an average of 1.1 hours per week for primary care physicians, 0.8 hours per week for medical specialists, and 0.7 hours per week for surgeons. And that doesn’t include the  amount of time they devote to formularies, which are intertwined with prior auth.

Primary care nurses spend an average of 13.1 hours per physician per week on prior auths and 3.8 hours per week on formularies, the study found. Nelson points out that ePA would allow these clinicians to convert most of the prior auth time to patient care duties.

Noting that 90% of prior auth requests require a phone call or a fax, Surescripts estimates the cost of completing these requests at between $2,000 and $14,000 per physician per year. Yakimischak adds that prior auths are required for 2% to 4% of prescriptions. Considering that billions of prescriptions are ordered every year, that adds up to a great deal of extra work. 

Leavitt says he gets half a dozen requests for prior auth each week. He turns them over  to his secretary, just adding a bit of clinical information and signing the forms after she completes them. “But it’s still a pain in the butt,” he says.

Boles says prior auth is a “big deal” in his practice. He tries to avoid the problem whenever possible by prescribing generics, he says, and his nurse is very adept at filling out prior auth forms when necessary. But some of his younger colleagues spend a lot of time on this task, he says.

NEXT PAGE: The cost of electronic prior authorizations

ePA can to reduce the amount of time that practices spend on prior auths by 70%, according to CoverMyMeds, but it is not without its own costs.

Surescripts is charging EHR vendors a monthly fee that it expects they will pass on to physicians, Deemers says. Yakimischak acknowledges this, but declines to specify how much these fees are.

DrFirst opposes charging physicians for ePA, Deemers says, because “doctors shouldn’t be charged for doing something they don’t want to do in the first place.” Nevertheless, DrFirst is offering Surescripts’ ePA product alongside its own free solution to see how the market will respond to the combination of price and service.

Boles thinks his EHR vendor won’t give him a choice of ePA solutions. But he says he’d rather not pay anything for ePA, because he’s already being asked to pay extra for many other EHR features, such as his formulary checker.

Leavitt, by contrast, says that he’ll compare how well the two solutions work if he has access to both of them. “If one is functionally better, and the price is minimal, I don’t care [about the cost],” he says.

NEXT PAGE: The impact to patient outcomes

Today, because physicians don’t usually know what requires pre-authorization, the process is “retrospective,” Yakimischak says. This means that pharmacies return prescriptions requiring a prior auth to the prescribing physician.

Surescripts’ and DrFirst’s solutions are set up to handle that scenario, but they also allow “prospective” prior auth requests. In that  model, physicians are informed in their e-prescribing workflow that a medication requires prior auth and can act accordingly.

This might improve patient outcomes, Yakimischak notes, because patients will be more likely to get their prescriptions filled if they’re pre-approved. “There’s a high abandon rate for prescriptions that have prior authorization at pharmacy. We want to nip that in the bud and improve the efficiency of the prior authorization and speed up the time to approval, so patients get the medicine in their hands quickly,” he says.

Dunn agrees that ePA will increase the chance that a patient will fill a prescription. “In many cases, when they have to wait for preauth and it doesn’t come quickly, they lose their desire to take the medication. What also happens is that it never gets approved. So what happens to the patient? They don’t get their medication.”

Leavitt feels that patients would benefit if he could tell them which drugs required prior auth at the point of care. But the main issue for his practice, he says, is that payers are “narrowing down dramatically” the prescriptions that they’ll cover without pre-approval.

“We have no way of knowing what requires pre-auth,” he says. “And there’s more and more of this. This is a really critical problem for us, so electronic prior authorization is a welcome solution, for sure.”