Prior Authorization and the Pharmacy Industry
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- • • Point • of • Care PARTNERS CONSULTANTS Point-of-Care Partners | Proprietary and Confidential Prior Authorization and the Pharmacy Industry Tony Schueth, MS Chief Executive Officer & Managing Partner
Transcript of Prior Authorization and the Pharmacy Industry
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Point•of•Care PARTNERS ~~~~~E1~ENT
CONSULTANTS
Point-of-Care Partners | Proprietary and Confidential
Prior Authorization and the Pharmacy Industry
Tony Schueth, MS Chief Executive Officer & Managing Partner
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Different Types of Prior Authorization
DRUGS DEVICES PROCEDURES Covered under Pacemakers Radiology
Pharmacy Benefit Infusion Pumps MRI Covered under Blood Glucose Meters Endoscopy Medical Benefit Nebulizers Chemotherapy
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Pharmacy ePA Timeline ePA SCRIPT Standard is Mature and Well Established
1996 2015 2017-18 HIPAA Passes, Implementation 2011 Names 278 as 2008 of SCRIPT- Start of Standard for ePA 2004 2006 Expert Panel CVS Caremark Based Standard integration
Pilot with EHRs MMA ePrescribing Formed/Roadmap Multi-SDO Task Pilots Involving Created Group Formed ePA
2013 2016 2003 2009 New Standard Expansion and
MMA Passes Published EHR Integration Minnesota Passes NCVHS Legislation Hearings Mandating ePA
2005 2007 Report to Congress Recommending a
New Standard
Source: POCP Primary Research Point-of-Care Partners | Proprietary and Confidential 3
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Current ePrescribing Flow
PHYSICIAN PRACTICE Request Eligibility, EHR with eRx System
A1
A2 Intermediary
Drug History
PBM or PLAN Response Claims Processing System Benefit
Plan Rules, Formulary, History
Electronic
Drug Info Formulary Pharmacy
Transmission (EDI) B
New Rx Refill Request
Refill Auth/Denial Change Request PHARMACY Database Database Directory
C Pharmacy Dispensing System
Point-of-Care Partners | Proprietary and Confidential 4
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New Standard Enables Multiple Workflows
Prospective Retrospective
Rx with PA info
Advises PA Approval
vs
RETROSPECTIVE PA PROSPECTIVE PA Without PA Info at Time of Prescribing With PA Info at Time of Prescribing
Prescriber
Rx without PA info
Request for info for PA
Pharmacy
PROCESS ING
Rejected: PA Needed
Payer Pharmacy
PROCESS ING
Advises PA Approval
Payer Prescriber
Prescriber
PA Info
Advises PA Approval
Pharmacy
PROCESSI NG
Advises PA Approval
Payer
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14% 19
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33%
Gaps in ePrior Authorization for Pharmacy
• Drug requiring PA flagged in o
14% 19
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33%
2014 2015 2016
nly 33% of the cases • Lack of EHR integration
• Lack of standardized criteria, which inhibits ability to
extract data from EHR
Source: AMA, HIMSS 2019 Point-of-Care Partners | Proprietary and Confidential 6
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ePA Timeline ePA SCRIPT Standard is Mature and Well Established
1996 HIPAA Passes, Names 278 as 2008 2011
Standard for ePA 2004 2006 Expert Panel CVS Caremark MMA ePrescribing Formed/Roadmap Pilot
Multi-SDO Task Pilots Involving Created Group Formed ePA
2013 2003 2009 New Standard MMA Passes 2005 2007 Minnesota Passes Published Report to Congress Legislation NCVHS
2015 Implementation
of SCRIPT-Based Standard
2016 Expansion and EHR Integration
2017-18 Start of
integration with EHRs
PRIMARILY RETROSPECTIVE
Recommending a Mandating ePA Hearings New Standard
Of physicians surveyed, 1/2 - 2/3 of PA are still completed via phone or fax. This represents time away from patient care, and higher processing costs for PBMs.
Source: POCP Primary Research Point-of-Care Partners | Proprietary and Confidential 7
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LESSONS LEARNED
Where Are We Going?
Mandatory electronic priorauthorization
for drugs dispensed under Medicare/Medicaid
Increased use of prospective (prescriber to pharmacy)
electronic prior authorization Seamless process – data will be
extracted from EHRs
Elimination of unnecessary PAs
Patient-specific, real-time accurate data and coverage information at point of prescribing
Handling of medical and prescription PAs within the
same application / EHR
Seamless integration of specialty medications
Addition of real-time benefit check Immediate alerts for PA required and
nonformulary prescriptions
Point-of-Care Partners | Proprietary and Confidential 8
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Lessons Learned
Key Stakeholders need to drive the process
“Boiling the Ocean” is not a successful strategy.
Staging and phasing is critically important
Structure and Process are necessary
Existing Standards must be augmented
must be facilitated by knowledgeable experts whose only “skin in the game” is success
Don’t be naïve…politics most definitely plays a role in
standardized solution development
Both Facilitation & Leadership are Critical
Industry leaders must step up but the process
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CONSULT ANTS
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