At the point of prescription, when physicians are choosing the medication they deem best for their patients, doctor and patient are on the same page. Patients want the treatment that can best address their condition with a successful health outcome and minimal side effects. They are relying on the expertise of their physicians, who are trained to make the clinical decisions as to the best treatments for their patients’ conditions. Seems to be a simple equation, right?
Unfortunately, there are roadblocks. In many cases, patients end up not being treated with the specific medication that their physician had prescribed.
One of the main reasons for this problem is that managed care plans are putting restrictions in place, often based on economic considerations rather than clinical benefits. In particular, a growing concern for physician practices is the need for prior authorizations (PA) – the requirement by a patient’s health plan to approve a specific medication for reimbursement, without which, many patients are unable to fill the prescription.
PAs have real impact on patients receiving the medication their physician deems best for their treatment: data suggests only 29% of prescriptions that require PAs are dispensed with the originally prescribed medication, and that only 60% are filled with any medication.
Primary among physician practice concerns regarding the PA process is the sheer volume of time required of practice staff (and sometimes the physicians themselves) to manage the PA process. In addition to completing an initial PA submission, health plans often require additional information or a resubmission of a second form. Then, when trying to contact the health plan directly, practice staff often experience long hold times and poor responsiveness. Many staff find the process to be a complex, frustrating experience and highly disruptive to their workflow.
Physicians utilizing the right PA service end up with more patients receiving the originally prescribed medication for their conditions and less administrative time spent on non-clinical activities in their practices. The “right” PA service is one that goes beyond simply providing a form to the practice. It is one that streamlines the process for the prescriber, provides a standard electronic PA process that eliminates the need to complete specific insurance forms, reviews PA requests prior to submission, follows up with the plan for a timely response, contacts the prescriber when additional information is required, manages appeals if required, and offers access to a call center staffed by responsive and well trained nurses and pharmacy technicians.. And last but not least, it is a service that provides this help and insight at no cost to the physician practice.
When the right PA service is employed, everyone wins: physicians, practice staff, and most importantly, patients.