Generating High PA Approval Rates: Important But Not Sufficient

Mar 28, 2018
For many pharmaceutical brands, managed care restrictions put tremendous pressure on the ability for patients to access prescribed medications, even when their physicians deem a particular medication to be best suited to treat their condition. To combat this challenge, many brands have engaged third parties to implement programs designed to assist physician practices with managing the cumbersome prior authorization (PA) process. While these programs may help generate higher PA approval rates, this metric alone is insufficient in evaluating whether the program is truly beneficial to patients and impactful for the sponsoring brand.
 
The PA management process is becoming increasingly complex and cumbersome — according to a 2017 AMA Prior Authorization Physician Survey, 84% of physicians say the burdens of the PA process are high or extremely high, and 86% believe those burdens have increased during the past five years. As a result, more and more physician practices are foregoing PAs altogether, often switching to alternative medications, even when they believe it is not as good as the originally prescribed therapy. In some cases, practices will initiate a PA process, only to abandon the PA request when plans require additional forms, information, or other time-consuming follow-up activities. The process itself – the delays, the requirements – have been shown to directly impact patient adherence: 78% report that PA can at least sometimes lead to treatment abandonment.
 
For brands that wish to overcome PA challenges, it is important to work with a third-party PA service provider that not only generates high approvals on PAs that are submitted, but also drives more PA submissions from prescribers. Below are a few examples of “break points” where prescriptions get lost because of PA requirements.
 
Most PA programs are triggered when a prescription is rejected upon adjudication at the pharmacy, prompting the pharmacy to send a PA form to a prescriber for fulfillment. Unfortunately, the majority of PA forms sent from pharmacies to prescribers are left unfulfilled. In one program PARx conducted with several hundred independent pharmacies, practices received up to four follow-up phone calls reminding them to complete and submit a partially completed PA form for a prescription that they had written, yet fewer than 40% of those PA requests were submitted. Those third-party programs that don’t include reminder calls are likely to generate even lower submission rates.
 
A second example occurs when patients redeem coupons or utilize a co-pay assistance card to receive a subsidized initial prescription. In cases where the managed care plan requires a PA, pharmacies generally process the coupon as a secondary insurer and neglect the PA altogether. However, when patients return to the pharmacy for a refill, they are often unable to obtain refills without a PA, which was never completed by their prescriber. In response, PARx Solutions created a co-pay card program that works collaboratively with coupon providers to create a partially completed PA request form, which is provided back to prescribers at the time the initial prescription is filled with the coupon. Providers receive a simple code that can be input in the PASS portal to access and simply complete the PA submission. 
 
Similarly, pharma brands often utilize patient “hub” services, providing a channel for patients to call and check their prescription coverage. When hubs perform such a benefit verification (BV) and learn that a PA is required, they may or may not notify the prescriber of their findings. By partnering with hub providers, a full-service PA support program can create a partially completed PA when the BV is completed and subsequently provide a reference code to the physician so that they can easily access and complete the PA submission, resulting in higher PA submission rates overall.
 

High PA approval rates are important, but what patients need and brands want is more prescriptions being dispensed with the originally prescribed drug. Accomplishing this goal hinges on both high PA submission rates and high approval rates.
 
Dan Rubin is President and CEO of PARx Solutions.
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