Study shows benefits of a centralized pharmacy-led prior authorization process

Pharmacy-led interventions in prior authorization (PA) processing resulted in a statistically significant benefit in improving time to PA approval, time to first fill, and time too pick-up.

According to study data published in the October 2016 edition of The Journal of Managed Care & Specialty Pharmacy (JMCP) reported that PAs “may improve appropriate use of prescription medications. Despite potential savings for health insurance plans, the PA process is time consuming for the ordering provider, pharmacy, and patient.”

The objective of the study was to compare the mean PA processing time between the new centralized clinic and usual care and provide secondary endpoints for PA approval rates, time to prescription fill, time to prescription pick-up, total staff time, and estimated labor costs.

Lead author, Timothy Cutler, PharmD , CGP Professor of Clinical Pharmacy, Divine Family Chair in Clinical Pharmacy and Director, UC Davis-Sacramento Experiential Program, said that the key findings are two-fold: one is the cost savings to the institution by using a more efficient process and the quality improvements to the patient to get that access to that medicine sooner.

“The third thing that I would say is that that then allows the physician the medical assistant and another team member, the pharmacist, to provide more care to patients in their clinic instead of being bogged down with the prior authorization process itself,” Cutler said.

At the UC Davis Health System (UCDHS), a new resource was developed designed to streamline the PA process using pharmacists and pharmacy technicians at a centralized “refill clinic.”

UCDHS is a 630- bed facility and primary care network with 14 clinics in the greater Sacramento area.

Pharmacy technicians and pharmacists at the refill clinic follow a standardized process for managing PAs. Then they used a protocol and collaborative practice agreement to authorize prescription orders, according to data from the study.

In addition, many clinics still follow a “usual care” process, where individual clinics are responsible for the PA workflow, employing medical assistants, nurses, and physicians to complete PAs.

Stacy Knox, PharmD, PharmD, BCPS, BCACP at UCDHS told Drug Topics that pharmacists provide clinical support to the technicians and explain a medication's place in therapy and why a particular drug is indicated for a patient. “When necessary, the pharmacists also interpret chart notes and lab results to help the technicians provide the information the insurance plans need to make coverage determinations,” said Knox.     

Knox added that the pharmacist also evaluates if a formulary medication could be appropriate for a patient and, if it is a good option, recommends the switch to the physician. “These activities help to minimize delays in starting therapy and improves medication access for patients, she said.

Knox explained that the clinic receives PA request from the pharmacy and then a pharmacy tech starts the benefits investigation process. They look to see what the existing benefits are that the patient has for their outpatient pharmacy medications and sometimes find that there is an opportunity often times they find that their might be an opportunity, with dual insurance for the other insurance go be billed and to fully utilize the patients existing coverage also while performing the benefits investigation, they were able to often research the formulary to make sure that what’s being prescribed is the preferred agent.

“If it something that demonstrates the potential to be changed and if it’s still an appropriate therapeutic interchange the tech will reach out to the pharmacist to do a chart review and see if in fact a formulary agent would be an appropriate alternative,” Knox said.

Knox added that that has the added benefit of saving patients the additional – cost for potentially out of – off formulary non- formulary medications as well as decreases the time needed to do a PA on something if there is an appropriate alternative that’s covered by the plan.

“Our research shows that it just wasn’t PAs, often times there were other alternatives therapeutic substitutions to another drug that was covered that were made by the pharmacy team whereas at the physician level that really didn’t happen very often,” said Cutler.

He said that it was less time consuming because the pharmacist and the pharmacy technician have a strong knowledge and understanding of insurance and coverage and therapeutic appropriateness.

Finally, study authors concluded that PAs may reduce health plan expenditures on medications but often transfers administrative costs to health care providers. Previous studies determined that the PA process is onerous to medical staff who are often pressured to complete PAs in a timely manner. A centralized PA process, study data concluded, may improve PA approval rates and time to PA approval, in addition to reducing total staff time spent on each PA.