Tackling the Prior Authorization Challenge: A Critical Task for Pharma

Talk with busy physicians and you’ll soon hear about the ever-increasing difficulty in getting approval for the medications that they believe are most appropriate for their patients. For pharma marketers, a superior efficacy, side effect and dosing profile is a necessary start, and a favorable managed care formulary position can be another positive step toward commercial success-but, more and more frequently, a prior authorization (PA) request must be approved before a medication can be dispensed and taken by the patient.

In other words, it’s not enough that the physician prescribes your product-something on which pharma often spends hundreds of millions of dollars in promotional investments, including advertising, sales, training, samples, conferences, and late phase research, all aimed at demonstrating that the product is best suited to treat certain therapeutic conditions. These efforts may lead a physician to write a prescription, yet there is no guarantee that the product will be dispensed, if the managed care plan restricts the patient from getting the medication.

Prior authorization (PA), is a stipulation by managed care organizations requiring a prescriber to seek approval for a specific drug by completing and submitting information before a drug can be reimbursed. The incidence and complexity of PAs is increasing, affecting more and more medications.

While most pharma executives are aware of PA requirements, they are sometimes unaware of the full implications. When a PA requirement is imposed, only 29% of patients end up with the originally prescribed product-and 40% end up abandoning therapy altogether. Not only is this negative for pharma and frustrating to prescribers, but it is even worse for those patients who don’t get the medication that could best treat their condition, or who don’t get any therapy at all. Further, the abandonment of prescriptions because of PA hurdles can have an “economic backlash” on the healthcare system as a result of additional office and emergency department visits, hospitalizations/re-admissions and other avoidable costs.

Most branded medicines face PA requirements across multiple managed care plans. While electronic PA processing (ePA) offers hope for a more efficient process in the future, for most managed care plans today the PA process can involve multiple steps for a physician practice: securing the correct form, filling it out with the required clinical information, appending clinical documentation in certain instances, submitting the form to the plan, and often completing and submitting a “follow-up, patient specific” form.

If the practice needs to call the plan either for clarification or to follow up on a submitted request, telephone “hold times” can be 20 minutes or more. Many physicians will tell you that the overall process can take 30-45 minutes for each PA submission. For many practices, the burden of the PA process causes them to abandon a preferred therapy in favor of a different formulary medication, even if they believe that the original medication would be better for their patient.

Astute pharmaceutical executives are recognizing that physician practices need support from pharma in navigating the complexities of ensuring that the prescribed medications actually make it to their patients. There are several available services that offer PA forms, without providing the broader suite of services that address important needs of physician practices. 

Increasingly, pharmaceutical companies are learning that a PA form is not enough and that a more effective PA solution will:

Make it easy. A universal PA input form makes it quick and easy to provide the required information, and a strong PA solution can save time for the practice by managing the process in its entirety, including making required follow up calls to the plans.

Eliminate denials for non-clinical reasons. A good PA service can reduce administrative denials due to reasons such as illegible or incomplete information, by employing a simple-to-complete electronic format that includes “drop-down menus” and “radio buttons” to prevent incomplete submissions.

Put an end to hold times. It is typical for plans to have telephone hold times of anywhere from 20 to 40 minutes before a practice can speak with a live person. A PA service that calls plans to follow up on PAs or provide additional information is very well received by prescribers.

Rely on professionals. The ideal PA solution should engage professionals such as pharmacy technicians, nurses, and medical assistants. It is important that the people who call the plans and the physician practices can “speak the language” when discussing clinical information.

Know that time matters. The PA process should be expedited wherever possible. A PA service that submits PAs promptly and follows up with plans on a timely basis can result in faster PA approvals, leading to quicker patient initiation of the “preferred” therapy.

Effectively addressing PA challenges as part of their core sales and marketing tactics can yield tangible and substantial benefits for pharmaceutical companies. For example, a sales representative took over a territory that had severe PA restrictions. While physicians preferred her product, they frequently switched to other formulary drugs to avoid the hassle of prior authorization. At the outset, this territory ranked 141^st in sales out of 150 territories nationally. After introducing practices to a PA service, practices in the territory developed a higher comfort level, knowing that the PA burden was being handled for them. As a result, this representative was able to increase sales while building strong relationships with practices, resulting in a climb to the 6^th ranked territory in the U.S.

Pharmaceutical industry leaders need to look closely at the toll that PAs are taking on their brands, and the extent to which their current PA initiatives are actually being used by prescribers. Providing their customers with the best PA solution is an effective approach to saving prescriptions and handling one of the most frequent and important barriers to physician prescribing and patient access.

Dan Rubin is President and CEO of PARx Solutions.