Prior authorization audits and innovations: Are we finally reducing the (PA)in?
By Lorraine L. Rosamilia, MD, FAAD
Aug. 9, 2023
Vol. 5, No. 31
Remedying the fragmented and inconsistent manner in which PA is designed and executed is no longer a fruitless thought experiment, however. The aforementioned studies, collaboration, and data shared between organized medicine and the legislature have created a toolbox for progress, while still accepting the spirit with which PA was designed: to foster cost-conscious and clinically effective care. For instance, the American Medical Association (AMA) website outlines PA studies, reform initiatives, and a state-by-state assessment of legislative efforts to improve the PA burden. (5) My state of Pennsylvania recently passed Senate Bill 225 (Act 146), thanks to grassroots advocacy from our state dermatology society, the AAD, other specialties aligning with our state medical association, and patient advocacy groups to enact time limits for medication PAs (2 business days for standard requests and within 1 day for urgent requests). The law also requires that PA and appeals can only be denied by a similar specialist to the prescriber initiating the request. In addition, it extends PA reform to all insurers, including Medicaid and CHIP plans, amongst other improved parameters. (6)
Further innovative concepts include a new proposed model for Medicare Advantage plans, exempting physicians from PA whose PA approval rate is high, expediting time limits for PA decisions, streamlining electronic submission, and pairing with state medical societies to reevaluate PA policies each year. (7) A study in press by Omar et al from the University of Pennsylvania outlines a model in which topical medications not covered by Medicaid be automatically substituted by ones that are, based on a physician-validated preferred prescription exchange list to avoid PA from the start. (8) Others propose that there should be insurance company incentives to expedite and streamline PA, such as avoiding patient reimbursements for out-of-pocket medication costs accrued during the PA and appeals process and leaning on affordable generic medications by removing them from PA lists all together. (2,3)
My department recently lifted some of the weighty strain of PA from the dermatologists and our staff by employing a clinical pharmacy team that processes biologic medication prescriptions, PAs, appeals, and assistance program applications. In addition, they follow up directly with the patient by overseeing lab monitoring and vaccination, medication handling, injection technique, and even some of the initial clinical follow-ups by telemedicine. It also encouraged our entire dermatologist team to streamline our criteria for prescribing and monitoring these agents so that the pharmacists could stand on solid and consistent ground when communicating with us and approaching the PA and the patients. If PA cannot be avoided, especially for costly biologic medications, a painless pharmacy partnership certainly can cool our frustrations and our patients’ confusion with this process.
In conclusion, PA is here to stay, but hopefully its execution will not be constantly fraught with staring angrily at a fax machine or filibustering a pediatric endocrinologist working for XYZ Health Plan to overturn your elderly patient’s biologic prescription appeal. Help is being defined and slowly on the way, thanks to our physician and pharmacist innovators, patient advocates, and, yes, our government, so that we can practice safe, affordable, and effective medicine and reduce all of our (PA)in.
Point to Remember: Much data supports the inefficiency and poor clinical outcomes related to impractical prior authorization (PA) implementation. There are numerous resources, including your own office/department (e.g., hiring a clinical pharmacist) and state (e.g., local medical societies) and federal (e.g., AMA) organizations to provide frameworks and enact laws to reduce the administrative burden of PA and get us back to seeing our patients.
Our editor’s viewpoint
Warren R. Heymann, MD, FAAD
Long before the internet, dermatologists would discuss clinical conundrums and practice management issues in “The Schoch Letter.” When insurers first challenged dermatologists regarding the appropriateness of a given prescription, an aggrieved physician writing in the Schoch letter said that his standard response to overturn the insurer’s decision was “BECAUSE I SAID SO!” I have a notion that such an approach would not get very far in 2023. I understand why there is a process to review requests for drugs that cost tens of thousands of dollars per year. What is infuriating is jumping through hoops to get a pound jar of triamcinolone for a patient with extensive atopic dermatitis. Most despicable is step therapy — prescribing cyclosporine before getting dupilumab approved is insanity. Fortunately, the insurer who demanded this requirement in New Jersey has now reversed its policy. Dr. Rosamilia references studies that mirror my own experience — in most cases, the PA ultimately gets approved; PAs incur administrative waste, potential for adverse effects, and poorer outcomes while waiting for an approval decision. Please see the Academy’s resources on step therapy for the status of step therapy laws in your state. Perhaps we are finally turning the corner on PA and step therapy, as Dr. Rosamilia suggests. The sooner the better.
.Guo LN and VE Nambudiri. Impact of prior authorizations on dermatology patients: a cross sectional analysis. J Am Acad Dermatol. 2021;85(1):217-20.
Jew OS, et al. Evaluating the effect of prior authorizations in patients with complex dermatologic conditions. J Am Acad Dermatol. 2020;83(6):1674-80.
Carlisle RP, et al. Administrative burden and costs of prior authorizations in a dermatology department. JAMA Dermatol. 2020;156(10):1074-8.
Vazquez T, et al. Insurance delays in the approval of biologic medications for patients with psoriasis and psoriatic arthritis. Arch Dermatol Res. 2022 Nov 14 (Epub ahead of print).
https://www.ama-assn.org/practice-management/prior-authorization/prior-authorization.
https://www.legis.state.pa.us/cfdocs/legis/li/uconsCheck.cfm?yr=2022&sessInd=0&act=146.
Anderson KE, et al. Improving prior authorization in Medicare Advantage. JAMA. 2022;328(15):1497-8.
Omar D, et al. Automated pharmacy substitution for medications not covered by Medicaid: a model for reducing the burden of prior authorizations in dermatology. J Am Acad Dermatol. 2023;88(1):258-60.
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