Category: Blog

Blog Post: Unprecedented Times….New Heroes

Week 5:  I sit here at my desk in my home office, I am amazed at how the world has changed in such a short period of time.  Here in the Boston area, we are in the midst of our peak COVID-19 surge, yet across the country, the practice of healthcare has changed dramatically.  For patients with chronic conditions, newly diagnosed patients, and even patients due for annual check-ups, visits to physician practices have either been postponed or gone virtual.

We have talked to a number of our top physician practices to see how their office was handling the current situation and learned that all of the practices are seeing only a small fraction of their patients live and in person.  However, people still need medications to treat their chronic conditions, and many prescriptions still require prior authorization in order to obtain managed care coverage.

PARx is fully operational to support our practices with their prior authorization needs, and our PASS system is accessible from any location with internet access.  Our call center staff, while working from home, continues to offer the same high levels of service as always, and PAs are being submitted and approved, allowing patients to obtain the medications that their providers deem best suited to treat their conditions.

May 6th marks the beginning of National Nurses Week.  The timing couldn’t be more appropriate to honor these heroes who are literally risking their lives to care for affected patients struggling to manage this horrible virus.  I would like to thank all those health care employees: physicians, nurses, nurse practitioners, physician assistants, and aides for their selfless service.

To everyone out there, stay safe, stay healthy, and know that we will get through this.

 

Does Formulary Contracting = Patients Will Get Their Prescriptions?

By Dan Rubin, CEO

When considering whether a health plan will actually pay for a pharmaceutical product that has been prescribed for a patient, it is important to understand that a product that is “covered” under contracts with the various plans and pharmacy benefit managers (PBMs) may not be readily available to their insured patient members.  All too often, it is difficult for patients to obtain a product that is covered by insurers and PBMs because of the imposition of prior authorization (PA) requirements, which have practical, real-world implications for health care providers and their staff.

As a case in point, a product manager recently stated that “we don’t have a PA problem, since we are under contract with 96% of the marketplace.” While there is some comfort in being on the approved formulary for a health plan or PBM, providers may still face significant market access restrictions when they prescribe the product, often resulting in lost product sales.

Being under contract means that a manufacturer has negotiated a position on the plan’s formulary, which no doubt is better than “Product Not Covered” or “Benefit Exclusion.”  However, with multi-tiered formularies being the norm today, branded products will more likely be placed in a second, third or more undesirable tier position, which will prompt a prior authorization or step edit before the plan or PBM adjudicators will pay for the medication.

PA is the requirement by a patient’s pharmacy benefit plan that providers must seek – and get – approval before a prescription product can be reimbursed for dispensing.  In many instances, this requires that the provider enter specific clinical information or test results justifying the PA request and/or provide confirmation that one or more preferred formulary alternatives have been tried.

[see the article on PharmExec.com for real-life example, additional details]

From the perspective of a pharmaceutical brand, there are factors to keep in mind; For brand teams and product managers, it is critical to think about PA requirements from the provider’s point of view:

  • Look closely at what your product’s contract status really means. If the product is covered on formulary, what tier is it on? What are the specific PA requirements for that tier?  Are the PA requirements similar or different across plans?
  • What is the PA burden that the practice faces from the perspective of both the prescriber and the office staff who usually process PA requests? Is a PA required in all or most cases?  What are the key criteria for approval?
  • What percent of prescriptions that are denied at the pharmacy because of PA requirements end up being filled as prescribed? Based on data from both pharmacy and electronic medical records, the percentage is often in single or low double digits.  How can you identify those practices with potential to improve their support of PAs?
  • How can practices be motivated to submit PA requests? How can your product investment effectively support practices to efficiently process PAs in terms of ease of submission, follow up with the PBM, updates on PA status, handling of requests for additional information, and support of appeals?

Product contracting for pharmaceutical products is important, but it is usually not sufficient by itself to assure broad market access.  In some ways, it can be likened to buying a ticket to a major sporting event – it does get you inside the doors of the arena, but the price can be high (think rebates) and you might be up in the rafters and maybe have an obstructed view. If you can see the scoreboard at all, it may not show the results that you desire.

The above is excerpted from an article by Dan Rubin, President and CEO, PARx Solutions, appearing on PharmExec.com. To read the complete article, please go to: http://www.pharmexec.com/does-formulary-contracting-patients-will-get-their-prescriptions.

“Set it and forget it” – keeping patients on the Rx their provider prefers

By Dan Rubin, CEO

Several years ago, while bored on a Saturday afternoon, I was “channel surfing” on my television and saw an infomercial for a rotisserie oven.  The spokesperson, Ron Popeil, repeatedly used the tag line, “just set it and forget it” to show how easy it was.  While “set it and forget it” may work when making rotisserie chicken, it does not usually get the job done when it comes to prescription prior authorizations (PA).

pharmacy-pa-problemsProviders may go through the process of completing and submitting a PA when writing the initial new prescription (NRx) for a patient.  However, most PAs are approved by the plan for twelve months or less.  If the prescriber has written a medication for chronic conditions, this means that the patient will not get coverage after the PA expires unless a second PA is submitted.  For many of these patients, it is appropriate to continue therapy for several years.  At PARx, we have found that providers resubmit PAs for their patients upon expiration only 5 or 6 percent of the time.  This presents a tremendous opportunity for patients, providers, and pharma brands.

Earlier this year, PARx launched our reauthorization program.  For interested sponsors, PARx provides notifications to providers a few weeks prior to a PA expiration.  The notification informs the provider that a PA has been initiated in the PARx PASS system and directs the provider to complete and submit the partially completed PA.  By making the reauthorization process simple for providers, this new program has produced spectacular results to date:

  • Upon receiving notification from PARx of the expiring PA, 50-60% of providers resubmit a PA request.
  • The PA approval rate for these second submissions is averaging 96 percent. Compared to the 5-6% submission rate without notification, this program creates thousands of additional prescriptions for our sponsor brands.
  • More importantly, patients are able to continue on their chronic therapy without interruption.

When it comes to PA, providers who work with PARx can “set it and forget it,” thanks to a timely renewal reminder – and rest easy knowing their patients will continue to have access to the Rx they deem best for their treatment.

Death by Prior Authorization

Pharmaceutical Executive | Dan Rubin | April 24, 2019

I recently read news that really brought home the real-life impact on patient care —really, on patient’s lives—of an effective prior authorization (PA) process. In February 2019, long-time disability rights activist and attorney Carrie Ann Lucas died prematurely at age 47 from a plethora of health problems, exacerbated by her disabilities.

However, according to a post following her passing on her Facebook page, her friends and family identify the root cause as the denial by her insurance carrier of “the one specific inhaled antibiotic that she really needed. She had to take a less effective drug and had a bad reaction to that drug. Read the full article.

%d bloggers like this: