5 PA Predictions for the Coming Year

As 2020 comes into view, we are considering how the pharmaceutical landscape is likely to change in the coming year, particularly with respect to patient access to prescribed medications. Below are a few predictions.

First, in a presidential election year, when both political parties will be focused on the cost of medications, price increases for pharmaceutical products will produce political fodder that will translate into public attention and payer resistance. Pricing flexibility is under scrutiny and managed care formularies are in place that have been shown to inhibit the dispensing of the most innovative and effective medications for significant medical conditions. This combination means that the makers of prescription medicines will need to make stronger clinical arguments to healthcare providers on why their medications warrant prescribing, as well as both clinical and health economic justification to PBMs and health plans on why their product should be approved for dispensing. Growth will only occur if pharmaceutical manufacturers develop more effective programs that address the shortfall between the number of prescriptions that are written and those that are actually dispensed by pharmacies.

Second, pharmaceutical industry growth will continue to be driven by innovative specialty products that require higher levels of service to optimize patient access. As such, pharma brands will need to step up their game by more tightly integrating patient and prescriber support services, including benefit verification (BV), PA/ePA management, and couponing/co-pay assistance. For example, many brands offer a benefit verification service in which a patient’s insurance coverage for a specific medication can be checked; a PA support service that assists providers who confront PA obstacles; and/or they offer co-pay assistance programs to make prescriptions more affordable. Too often, these support services are offered independently and not as an integrated suite. 

In 2020 and beyond, more brands will integrate these services so that if a BV check determines that a PA will be required to obtain coverage, it will immediately initiate a PA for the provider to complete-even if the prescription hasn’t yet been written or adjudicated at the pharmacy.  Today, a BV can result in the provider selecting a less preferred product-or a co-pay card may be utilized to pay for a new prescription-but the initial plan adjudication is ignored since the prescription can be paid for with the co-pay card. As a result, when patients go to obtain refills, they do not have coverage since the initial PA was never submitted. In 2020, more brands will initiate PA services immediately upon use of a co-pay card to ensure that patients can easily obtain refills, even if the initial fill was paid for by the co-pay card. Forward-thinking brand teams will incorporate programs that seamlessly integrate BV, PA initiation, and co-pay card application.

Third, there will be increased realization that e-prescribing may be an efficient way for a provider to submit a PA to a pharmacy, but ePA will not be the panacea that many expect it to be because of poor alignment with the office workflow for most providers. In a high proportion of cases, the e-prescribing platform is engaged after the patient has left the office. As a result, the supposed benefit of “prospective” electronic prior authorization (ePA, whereby a plan/PBM sends back in real time a set of clinical questions in the provider’s e-prescribing system) does not occur-and then the question set sits unanswered in a queue. In fact, the incidence of prospective ePA has declined over the last couple of years and data from a major e-prescribing platform reveals that when an ePA is triggered in their system, the question set is completed for most medications less than 10% of the time. While the provider selects the medication (and may or may not initiate the e-prescription), PAs are frequently handled by someone else in the provider’s office, usually much later than when the prescription was written. Due to these factors, pharma brands need to develop product support strategies and tactics that address the fact that they lose prescriptions more because of office workflow and timing and less because a provider consciously decides not to pursue a PA.

Fourth, many pharmacies will reevaluate how they handle PAs and incorporate more effective approaches. For most pharmacies, when a prescription is adjudicated and denied due to PA, the pharmacy system can electronically “push” a PA notification and/or PA form directly to the prescriber. However, few (typically less than 25%) of these “PA required” notifications result in a PA request being submitted to the plan. As a result, the pharmacy has little to no visibility into the process and most pharmacists report that the only way to know if a PA has been submitted and/or approved is to re-adjudicate the claim, often daily until they see a final outcome.  Pharmacies want to support their customers and help them get the medications that their providers have prescribed, and they will seek out new services to help manage PAs while providing greater transparency into the process and driving higher provider response rates.

Fifth, and finally, I predict that pharmaceutical brands will get much smarter with their patient access program spend. Many programs being utilized today by pharma brands charge when pharmacies notify providers of a PA requirement, whether or not a PA is even submitted to the plan. More brands will utilize PA programs whose fees are charged only when PAs are submitted to plans, yielding higher returns on their program investments.

In closing, widely cited data indicates that when PA is required, the originally prescribed product is dispensed less than 30% of the time-and patients forgo drug therapy over 40% of the time. In fact, the study reporting these numbers is 10 years old. More recent data from a large pharmacy network suggests that the results are even worse in 2019, with less than 20% of PA products being dispensed as originally written. That should be enough reason for pharma brands in 2020 to address more effectively the factors that frustrate providers and cause so few patients to receive the medications that they need.

Dan Rubin is president and CEO of PARx Solutions