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Taking the pain out of prior authorization

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How we're revamping the prescribing process

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Truly, we live in an age of medical wonders. Modern physicians and their patients can now routinely access high-tech medical procedures and revolutionary new drugs undreamed of within living memory.

But along with their new power, today’s advanced treatments often come with some very specific uses. New drugs, especially, can be highly targeted, to the extent that they will only be effective for certain types of a disease, or only for people with precisely-defined genetic features. And, of course, all of this is often at an extremely high cost.

Given these new complexities and high costs, insurers and other coverage providers use control mechanisms like prior authorization (PA). PA helps to confirm that a treatment or drug prescribed by a physician is covered by the patient's health plan.

But even more importantly, PA also helps determine that the requested care is the most appropriate care and that it will occur in the best setting. This helps produce improved health outcomes and lower health care costs by reducing duplication, waste, and unnecessary treatments.1

PA is a critical tool in the pharmacy benefits management world. Yet, while PA provides an undeniable benefit, doctors and patients almost universally dislike the PA process. The reason is simple: the way we have traditionally gone about PA is disruptive and frequently causes delays.1 These delays add cost and can result in lower medication adherence and poor health outcomes.

Here’s a simplified illustration of how traditional PA can lead to frustrating delays:

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On the left we can see that someone has gone to see a doctor. The doctor decides to issue a prescription. However, with the way things are now, there are many questions – things she does not know and cannot know about the patient and their coverage.

One key point is that this is not just about the added frustration. PA can also affect the quality of care. According to an American Medical Association survey, two-thirds of physicians said they waited at least a few days for medication approvals, while over 10% said they waited for more than a week.1

Learn more about the health impact of PA and exactly how and why the PA process is so cumbersome and frustrating for doctors and patients alike. Click on the button below for a closer look:

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Pharmacy insight closer look - link to learn more about the history and evolution of discount cards

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The OptumRx solution

Clearly, this situation is crying out for a solution. In response, OptumRx has created a new tool, called PreCheck MyScript. PreCheck MyScript gives physicians access to patient-specific PA information in real time at the point of care, and brings much-needed efficiency to the PA process.

PreCheck MyScript transforms what was previously a labor-intensive, sequential process into an efficient, one-step encounter. PreCheck MyScript frees doctors from clerical PA tasks. And patients get their medicines faster, start their therapies sooner, and ultimately, achieve superior clinical outcomes.

PreCheck MyScript: We can see clearly now

PreCheck MyScript is able to transform the old PA process because for the first time, doctors can now have all of the relevant information about a patient at their fingertips: insurance coverage, formulary rules, potential drug-drug interactions, prescribing guidelines – even lower-cost alternatives. Plus, the entire PA process can be contained within the PreCheck MyScript tool, and resolved on the spot in most cases.

Here is a schematic outline of PreCheck MyScript:

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Look back to the “Day 1” image above. See the “question mark” box right next to the “doctor visit” box? That’s to illustrate how many unanswered questions there are in the ordinary PA process.

Now, PreCheck MyScript leaves no unanswered questions. Doctors can even see a “trial” claim – the system shows her exactly how this drug will be reimbursed for this patient.

Dr. Sumit Dutta, Senior Vice President & Chief Medical Officer of OptumRx, explains the advantage:

From a physician’s perspective, there are a lot of benefits to prior authorization such as keeping you informed of contraindications or efficacy issues for a given medication. But if we can do prior authorization more efficiently, we can have greater compliance that will benefit patients both from a cost perspective as well as a health and safety perspective.

– Dr. Sumit Dutta, Senior Vice President & Chief Medical Officer of OptumRx
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Already, PreCheck MyScript is paying dividends. Providers using PreCheck MyScript reported that more than 30% of their prior authorizations were initiated electronically or avoided altogether. By seamlessly condensing the PA process into the span of the office visit, PreCheck MyScript avoids unnecessary delays, and also eliminates the chance a patient will learn of a claim’s rejection at the pharmacy counter. Now when the prescription is sent to the pharmacy, that patient can be fully confident that their prescription will be ready, and they can begin the healing process.

Giving doctors customized, real-time data about each patient, while the patient is in the exam room, is the best way to fix the PA process. PreCheck MyScript from OptumRx avoids unnecessary delays, and also means less effort for providers. The result is better health outcomes and lower out-of-pocket costs for members.

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References

  1. Family Practice Management. Beating the Prior Authorization Blues. 2016 Sep-Oct;23(5):15-19. Accessed at: http://www.aafp.org/fpm/2016/0900/p15.html
  2. American Medical Association. 2016 AMA Prior Authorization Physician Survey. Accessed at: https://www.ama-assn.org/sites/default/files/media-browser/public/government/advocacy/2016-pa-survey-results.pdf
  3. Managed Healthcare Executive. Three reasons for nonadherence. July 14, 2017. Accessed at: http://managedhealthcareexecutive.modernmedicine.com/managed-healthcare-executive/news/three-reasons-nonadherence
  4. Vox. The fax of life. Oct. 30, 2017. Accessed at: https://www.vox.com/health-care/2017/10/30/16228054/american-medical-system-fax-machines-why
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STATEMENT REGARDING FINANCIAL INFLUENCE:
This article is directed solely to its intended audience about important developments affecting the pharmacy benefits business. It is not intended to promote the use of any drug mentioned in the article and neither the author nor OptumRx has accepted any form of compensation for the preparation or distribution of this article.