Prior Authorization (PA) is considered a necessary evil in today’s prescribing process.
This is particularly true for specialty drug prescribing, where the therapies being prescribed cost anywhere from $10k to $100k per year, and up. Due to the complexity and expense associated with these specialty therapies, prior authorization can be quite cumbersome, particularly when you take into account that the primary means for sharing information is still fax and phone. It is a complex and outdated process that often leads to piles of paperwork, unnecessary delays and frustration amongst patients and clinicians, including physicians, nurses and medical assistants.
To put the prior authorization burden into perspective, let’s look at the numbers. A recent AMA survey of 1,000 physicians providing 20 or more hours of care a week showed that doctors receive an average of 37 PA requests per week. You may or may not think that 37 is a lot over the course of a week, but those 37 PA requests took an average of 16.4 hours to process. Extrapolate 16.4 hours a week over a year and clinicians are spending around 40% of their time annually doing paperwork, making calls and or sending faxes just to navigate the PA process and get medications to their patients. The time burden is so great that about one-third of physicians have staff members exclusively dedicated to prior authorization.
So, where in the process do PA delays typically occur? Most delays occur as a result of requests for additional information and or corrections to paperwork. Let’s take a closer look at some of the challenges associated with PA:
• Health care providers still rely on fax order forms: Nearly half of all orders take more than 20 minutes to complete, with some taking more than 30 minutes. 75% of orders take more than five days to fill. Up to 70% of PA requests are denied due to incomplete information.
• Providers find out about PA requirements too late: 68% of providers discover PA is required after the order has already been submitted.
• Critical information is left behind in EMRs: Nearly half of providers said they couldn’t download and save information from their EMR.
• Communication breaks down along the way: More than half of providers do not get confirmation a patient has received their medication.
Most often patients in need of specialty drugs are suffering from serious conditions that come with horrendous symptoms that rapidly degrade their quality of life without treatment. It is astonishing to think that it often takes weeks to get specialty therapies to patients after diagnosis. As a community of healthcare professionals and innovators, we need to redirect the process so the right drug is delivered to the right patient at the right time. This will almost certainly decrease physician, clinician and medical staff burnout and help us to achieve the “holy grail” of healthcare; improved patient outcomes.
Time for a new era
So, why has every other industry digitized communications while clinicians still rely on fax machines to secure authorization from insurers and get appropriate medications to patients in need? It’s a great question, and one we’ve been asking ourselves for years. I can tell you there is no single simple answer to that question. However, I would argue that it is time to stop asking why and start asking how. How can we fix this system so that patient suffering is reduced, outcomes improve, and our healthcare dollars are spent as efficiently as possible?
The answer is rather straight-forward. We need to be creative and use the technology that is available today and apply it in healthcare. If successful, not only will we be able to streamline processes and decrease operational expenses, but it can literally help save patients’ lives. The challenging part is that we need to have the courage to break down the walls between all stakeholders in the ecosystem and create a new level of transparency which healthcare is in such desperate need of.
Today, there are companies working hard to crack the PA code by digitizing the complex, manual prescribing process. There is no rational reason to remain tied to the slow and fragmented methods of data exchange, particularly at the cost of clinicians’ time and patients’ health. With innovative methods and new technology, the PA process can be streamlined, maybe even eliminated, allowing patients to get their approved therapy in days, not weeks. In turn, we will empower clinicians to focus their time and efforts on patient care. With a new approach, patients will receive the treatment they need when they need it and overall healthcare costs will decline for these patients.
At ZappRx, we are certain our collective efforts will pay off and, when we are successful, we will have helped our medical professionals rediscover why they studied so hard, struggled through university and made the sacrifices they’ve made – to feel the unmatched fulfillment that comes with caring for people in need of quality care.
James Cornicelli is the vice president of corporate strategy at ZappRx, a digital health company that reduces the administrative burden associated with prescribing specialty medications.
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