As healthcare stakeholders investigate ways to leverage health IT to mitigate clinician burden and improve patient safety, the next frontier for the digital health transformation could be streamlining the arduous prior authorization process through electronic prior authorization.
Automating prior authorization could result in higher quality care by cutting back on clinician burden and providing patients with their medications in a more timely manner.
What is electronic prior authorization?
Prior authorization is a utilization management strategy that payers use to ensure patients access the most cost-effective medication available for their clinical needs.
When a drug has prior authorization requirements, providers must submit certain documents to the payer for permission to prescribe the drug. However, the traditional prior authorization process is time-consuming and can lead to delays in patient care.
A 2019 AMA survey found that 64 percent of providers have to wait a full business day to receive prior authorization feedback from payers; 29 percent reported that they had to wait at least three business days.
This delay can lead to patient care setbacks. The survey found that for 91 percent of providers, prior authorizations delayed patient care; 48 percent reported that prior authorizations often or always have this effect.
Delayed prescriptions due to prior authorization can lead to patient safety issues. Nearly a quarter of providers (24 percent) said that a prior authorization-related delay has resulted in an adverse health event for a patient and 16 percent said that the delay led to hospitalization.
What’s more, the arduous prior authorization process places a sizable administrative workload onto clinicians. Almost nine in ten providers (86 percent) reported that the prior authorization burden was high or extremely high, averaging over 14 hours per week to complete 33 prior authorizations.
However, health IT could alleviate some of the clinician burden while also helping patients receive their medications sooner.
Electronic prior authorization (ePA) aims to speed up the process by sending prior authorization documents digitally instead of via phone or fax. ePA can be integrated into EHR systems to allow providers to easily request prior authorization within their clinical workflows.
Is ePA effective?
To better understand how electronic prior authorization might impact patients and providers, America’s Health Insurance Plans (AHIP) launched the Fast Prior Authorization Technology Highway (Fast PATH) initiative in early 2020.
Six payers—Blue Shield of California, Cambia Health Solutions, Cigna, Florida Blue, Humana, and WellCare (now Centene) participated in the project, which ran for approximately 12 months. Availity and Surescripts served as the program’s health IT partners. RTI International evaluated the results as a third party. Point-of-Care Partners acted as an advisor.
After implementing ePA, the total number of prior authorizations jumped by 34 percent. A third of these transactions took two hours or less, compared to before when 24 percent of prior authorizations took two days or longer to fulfill.
More than 60 percent (62 percent) of prior authorizations were electronic after the health IT solution was implemented, and traditional prior authorizations were cut nearly in half. The report authors noted that ePA had little effect on the rate of approvals.
Most providers who used electronic prior authorization had positive feedback. Six in ten providers who used prior authorization regularly said that ePA made it easier to know whether they needed to request prior authorization.
Approximately the same number of providers (57 percent) who were well-versed in prior authorization said that the ePA requirements were easier to understand, and half of them said that the prior authorization decision was easier to view.
Among less experienced providers, the results were less extreme. Less than half (47 percent) said that it was easier to understand if prior authorization was required with ePA, while 43 percent said they did not observe a difference.
Providers who used ePA for most of their patients reported less administrative work related to prior authorizations; 54 percent had fewer prior authorization-related phone calls and 58 percent had fewer faxes related to prior authorization.
However, across the entire provider population, nearly half of clinicians reported no change in the volume or time spent on phone calls and faxes when using ePA.
Overall, seven in ten respondents who used ePA for most of their patients reported that the tool sped up care delivery. Less than three in ten providers said that the amount of time for care delivery was unchanged (27 percent).
Across the entire provider population, 43 percent agreed that ePA increased the speed of care delivery, and nearly half reported no change in care delivery speed (49 percent).
“The review of over 40,000 transactions showed the impact electronic prior authorization makes in health care,” said Denise H. Clayton, research economist of Health Economics and Evaluation at RTI International. “Because clinicians and their staff report more benefits from ePA when they use it more often, greater provider adoption of ePA could help further realize its promise.”
Is there an appetite from providers for this?
About 83 percent of physicians surveyed by Surescripts in 2016 reported that ePA is a top priority, and 64 percent agreed that EHR vendors should provide a service for streamlined prior authorization.
EHR vendors also acknowledged the growing importance of adding electronic prior authorization to their systems; 88 percent of vendors stated that they are aware of the demand for this ePA from their customers. Additionally, about 86 percent of EHR vendors said that ePA is a functionality that customers anticipate the systems to provide.
A June 2020 AHIP survey revealed similar findings; almost 85 percent of payers saw prior authorization automation as a key point of collaboration with providers. Approximately 90 percent of plans said that they were streamlining prior authorization processes for prescription medications (91 percent) and medical services (89 percent), primarily relying on ePA in each scenario.
“Many EHR software systems have incorporated electronic prior authorization capabilities, but the functionality may not yet be a standard option, despite vendor acknowledgment that it can improve clinician workflow and quality of care,” explained Joe Delisle, Surescripts senior business management analyst.
“The inefficiency of manual PA processing translates into hours of wasted time, contributes to workflow inefficiency and impedes a practice’s ability to deliver optimal and timely care,” said Delisle. “The time to enable electronic prior authorization is now.”
ePA Implementation, Use Challenges
Despite the promise of ePA, and an appetite from providers to adopt it, there are some challenges. A study published in JAMA Network Open found that misfiring issues and provider education are keeping ePA EHR integrations from achieving success.
Researchers implemented ePA at a large US healthcare system in two phases in September and November 2018, and used the later-implementing sites as controls.
Using EHR and pharmacy data, the study authors matched epA prescriptions with non-ePA prescriptions based on insurance plan, medication, and site, before and after ePA implementation.
Overall, 64.2 percent of ePA prescriptions (24,930) were filled, compared to 68.8 percent of control prescriptions (26,731), a negligible difference.
The researchers suggested several possible reasons for this result.
First, ePA fired for less than two percent of prescriptions, which is less than the nationwide average. This suggests some potential misfiring.
There were no substantial differences for commonly used medications for chronic illnesses. However, there were larger gaps in medication adherence for dermatological agents and lifestyle medication for ePA compared to control prescriptions.
The study authors suggested that ePA may have misfired for medications that did not require prior authorization, such as vaccinations, low-cost topical medications, and glucose supplies.
Additionally, since not all healthcare payers have ePA capability, providers may have been using ePA and traditional prior authorization processes simultaneously. In fact, the study authors noted that approximately 75 percent of providers that use ePA leverage several prior authorization solutions.
Next, the authors noted that upon ePA EHR integration, providers may have faced a learning curve that hindered them from using ePA to its fullest capacity. For instance, prior authorization denial in-basket messages may not have been read immediately.
However, the authors noted that over time, these barriers could diminish with use.
Strategies for improved ePA utilization, integration
The JAMA researchers suggested that reducing fragmentation between payers and ePA could reduce the potential misfiring of medications, especially because payer information may not have been up-to-date.
“This may be increasingly possible as integrated delivery networks and risk-bearing contracts with insurers grow, due to focus on the use of technology to improve care coordination,” they explained.
Additionally, integration of data and processing with pharmacies into the EHR may enhance efficiency.
“These findings offer several broader lessons for health information technology interventions, particularly the importance of testing whether the interventions that are supposed to improve care actually do,” the study authors explained.
“Health information technology represents just one type of tool, and, in this case, computerizing the prior authorization process may not have actually addressed the barriers to efficiency, especially when not all payers participate in the technology,” they continued.
The researchers suggested that future studies investigate whether different ePA implementation processes could improve efficiency.
“This research emphasizes the need for rigorous study of these types of interventions not only to inform effectiveness within healthcare systems but evaluate any issues with implementation,” the authors explained.
ePA could benefit both providers and patients, but like many health IT initiatives, true success will only come from widespread use and sufficient provider training.