ATLANTA—Obtaining prior authorization to ensure services or prescription drugs are covered by a patient’s health plan consumes staff time, and delays or denials may cause patients to abandon treatment, according to speakers at the 2019 ACR/ARP Annual Meeting. In a session on Nov. 10, the experts shared tips to smooth the process.
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Train Staff on Rheumatic Diseases
Prior authorization may be required due to quantity limits imposed by health plans on medications, step therapy requirements, to check if medications are excluded from a plan’s formulary or to ensure coverage for high-tier, expensive drugs. Staff training is the first important step, said Jessica Farrell, PharmD, associate professor of pharmacy practice at Albany College of Pharmacy and Health Sciences, New York.
In a 2017 AMA survey of 1,000 practicing physicians, 64% reported they waited at least one business day for prior authorizations from health plans, 23% said they waited three to five business days for these approvals, 86% said time spent on prior authorization processes has increased over the past five years, and 78% reported that prior authorization delays or denials sometimes lead to prescribed treatments being abandoned by their patients.1
Rheumatology practices report significant delays in their patients’ access to treatments due to prior authorizations. One study in Arthritis Care & Research showed that 71% of 225 patients who were prescribed an infusible medication required a prior authorization and waited longer to receive their drug.2 More than 50% of rheumatology providers in the study reported their staffs spent up to 20 hours per week on prior authorizations.
“This can … cause patients to be on higher doses of steroids while they wait, being in flares for longer periods of time, and their diseases being uncontrolled,” Dr. Farrell said. “This hurts patient outcomes.”
Prior Authorization Tips
Dr. Farrell suggested the following:
- Invite a pharmacist or nurse educator to talk about diseases and FDA-approved therapies;
- Train staff on common ICD-10 codes for rheumatic diseases to avoid clerical errors and recognize which codes often flag denials;
- Create a comprehensive list of common medications currently approved for rheumatic diseases. Infusible medications may have different dosing regimens for each indication, so a plan may deny coverage due to the wrong dosing regimen; and
- For new staff, develop standardized work flows that include steps for prior authorizations to be reviewed by someone experienced in the process.
“Identify specific staff to handle certain prior authorizations, such as for infusibles, so they learn the process,” Dr. Farrell said. “They’ll develop their own tips and tricks and become more efficient.”
Some electronic health record (EHR) systems include patient profiles with such details as medical history and past medication failures, so benefit investigations or appeals following coverage denials are easier to perform than in the past, said Dr. Farrell. EHRs may include calendars that show when a patient’s drug prior authorization will expire and needs to be renewed.
If coverage is denied, request an expedited appeal. Review denial letters to pinpoint the payer’s rationale, then respond with a letter that includes the patient’s medical history, past medication failures and evidence, such as abstracts, to support the requested therapy or as justification for off-label use. “If you get to a peer-to-peer review step of an appeal, you can also ask for a rheumatologist to review it. Many plans have specialists on staff who understand our disease states,” said Dr. Farrell.
Utilization Management Tools
Utilization management tools, which include prior authorizations, non-medical switching, medication quantity limits and step therapy requirements, are used by payers and pharmacy benefit managers (PBMs) to reduce their own costs, but in the process can also “restrict our ability as rheumatologists to prescribe the right medicine to the right patient at the right time, and interfere with the practice of medicine,” said Madelaine A. Feldman, MD, FACR, clinical instructor and assistant professor of medicine at Tulane University School of Medicine, New Orleans.
“Medication quantity limits are fine for safety purposes, but some PBMs use them to require you to go through their mail order service to get a 90-day supply. Often, if you utilize a local pharmacy you are allowed only a 30-day supply, or it may not count toward your deductible, and sometimes the drug may not be covered at all,” she said.
Non-medical switching occurs when a PBM changes a formulary for cost reasons, resulting in even stable patients having to change medicines because their current medication is now unaffordable or is no longer covered.
“They can switch the drug to a higher formulary tier. They can refuse to accept a patient’s co-pay card, or they can take the drug off the formulary altogether,” said Dr. Feldman. “This ignores the patient’s well-being and puts profitability first.”
Non-medical switching may lead to worse disease outcomes, flares or costly hospital visits, she said. A 2018 study by the Maine Bureau of Insurance showed the state’s insurers reported 300 formulary changes in just one quarter.3 “For those patients affected, 80% had increased out-of-pocket costs, whether it was for adding a prior authorization requirement, step therapy, higher tiering or the drug being dropped from the formulary. Higher out-of-pocket costs can also come from increasing use of other medications, such as antibiotics for infections.” Over half of coverage appeals were denied, the report showed.
Step Therapy Delays
Step therapy, or fail-first policies, require patients to take drugs from a preferred list first. This preferred list, particularly for specialty drugs, may have a lower cost to the PBM, but can have a higher list price than some non-preferred drugs. Some step therapy policies may even require patients to fail several drugs with the same mechanism of action before allowing a more innovative drug to be used, she said.
The fact that step therapies are so varied among payers and PBMs suggests these policies are not based in clinical evidence and, in fact, are based on the profitability of the drug for the PBM. A PBM may receive kickbacks in the form of rebates and myriad fees to place certain drugs on formularies, she said. “In response, the PBM rewards certain manufacturers with preferred placement, and that’s the holy grail, because patients must step through your drugs.” When payers refuse to cover a patient’s drug or increase the cost share, patients may abandon treatment altogether, often leading to increased disease activity, she added.
Dr. Feldman co-authored a white paper based on a survey of 634 patients with rheumatoid arthritis, psoriasis, Crohn’s disease and other inflammatory conditions. Almost 40% of patients who stopped their treatments because of step therapy protocols said they did so because the drugs were ineffective, and 27% stopped taking their medication because their insurance company took it off the formulary, making it too expensive.4
Although step therapy may save some costs for the payer and lower overall drug utilization, it can negatively affect patients, according to Dr. Feldman. In a 2019 retrospective study comparing the effectiveness of medications for 3,993 patients with rheumatoid arthritis and 1,713 patients with psoriatic arthritis, patients whose plans had step therapy requirements reported lower treatment effectiveness, often due to low adherence to therapy.5
“PBMs constantly talk about cost savings, but it’s the cost to them, not the cost to our patients, who often have to pay a co-insurance on the list price of a drug while the PBM acquires it, on average, at 50% off of the list price,” said Dr. Feldman. “It has been shown that restrictive utilization management tools can force drug switching, increasing the risk of flares and adverse events.”
Get involved in ACR, ARP and state rheumatology association advocacy efforts to promote legislation to restrict these policies, said Dr. Feldman, who cited recent successes, including a new Illinois state law, HB 0465, that eliminates gag clauses that prevent pharmacists from advising patients about lower-cost treatment options, eliminates co-pay accumulators and requires more transparency on the activities of PBMs.6
Learn how you can become an advocate for your practice and your patients in the ACR’s Legislative Action Center.
Susan Bernstein is a freelance journalist based in Atlanta.
- American Medical Association. 2017 AMA prior authorization physician survey.
- Wallace ZS, Harkness T, Fu X, et al. Treatment delays associated with prior authorizations for infusible medications: A cohort study. Arthritis Care Res (Hoboken). 2019 Sep 10.
- Maine Bureau of Insurance. Quarterly report of formulary changes for 1st quarter 2019: January 1 through March 31, 2019. 2019 Jul.
- Snow J, Feldman, MA, Koppel J. The impact of step-therapy policies on patients. White paper. Questex LLC.
- Boytsov N, Zhang X, Evans KA, Johnson BH. Impact of plan-level access restrictions on effectiveness of biologics among patients with rheumatoid or psoriatic arthritis. Pharmacoecon Open. 2019 Jun 8; doi: 10.1007/s41669-019-0152-1. [Epub ahead of print].
- Illinois General Assembly. Bill status of HB0465: 101st General Assembly.