As concern grows about the cost of pharmaceuticals, health insurers have turned to "prior authorization" rules to make sure that expensive medicines are needed before they are dispensed to patients.
Cost is a key benefit, health plans argue, but the programs also can prevent safety problems, since insurers sometimes have access to more information about all the medications being taken by a patient, and can flag the potential for adverse interactions.
Doctors and clinics say they understand the rationale, but have a different take on the trend.
It can take a long time, they say, to supply information to insurers that might justify a prescription, and the requirements vary. These prior authorization reviews — called "PA," for short — can be triggered by a number of factors, doctors say, including a prescription that exceeds normal quantity limits for a drug or "step therapy" rules where insurers want patients to first try other similar drugs before covering the prescribed medication.
The pharmacy division at Fairview Health Services has waded into this fray with the goal of streamlining the PA process.
State law in 2016 required that health care providers and insurers move to electronic prior authorization in hopes of boosting efficiency. Fairview made the change, but also established a central prior authorization team to field requests for more information from insurers, and quickly supply responses to "pharmaceutical benefit managers" (PBMs) that handle the process for health plans.
Whereas obtaining prior authorization could take few days even with the move to an electronic process in January 2016, the centralized team at Fairview has worked the average wait time down to less than two hours. The process includes checking with the patient's PBM the night before an appointment to see whether a given medication requires PA, so doctors in the exam room can consider alternatives.
The efficiency gains are important not just because they relieve doctors and clinics of the tiresome task of obtaining prior authorization, officials say, but also to ensure that patients get access to their medications more quickly.
"Sometimes you run into compliance issues," said Amanda Robinson, a manager with Minneapolis-based Fairview. "If it goes from taking two hours to just two weeks, the patient might just say: Forget it."
The goal of making the prior authorization process electronic was to reduce the time for approvals to just a matter of seconds, said Aubree Dorr, who managed the Fairview program until recently. "The fact that we've got that down to two hours and we're really celebrating — it's still not good enough," Dorr said
Between 2004 and 2013, average retail drug spending in employer health plans held relatively steady. After adjusting for inflation, per-person spending during the time period grew from $909 to $947, according to an October report from researchers at the Kaiser Family Foundation. Costs shot up 13 percent to $1,053 per enrollee in 2014 — just about that time that a surge in high-cost "specialty medications" was grabbing headlines.
New medicines to treat hepatitis C, for example, offered most patients the shot at a complete cure for the disease in just three months, but at a cost of nearly $1,000 for each pill taken daily.
While some specialty pharmaceuticals are dispensed at retail pharmacies, they account for many of the drugs available on an outpatient/nonretail basis. The Kaiser study found these outpatient medications costs grew more dramatically — from $85 per person in 2004 to $175 per person in 2014.
A separate survey released in September by the foundation and the Health Research & Educational Trust found that 82 percent of employer-sponsored health plans were using prior authorization to contain the cost of specialty drugs.
The big dollars involved, and wide use of PA rules, help explain why prior authorization has become a recurring source of debate at the State Capitol. It's a front-and-center issue for trade groups that represent doctors and health insurers.
"We've seen it far too often," Dr. David Agerter, president of the physician group, said in a statement. "Patient care is disrupted by the bureaucracy of prior authorization."
Jim Schowalter, chief executive of the Minnesota Council of Health Plans, said in a statement: "We've tried writing a blank check for medications. It turns out to be neither safe, effective nor affordable."
Before Fairview launched the central prior authorization team, patients were more likely to go to the pharmacy for a prescription, only to be told the drug couldn't be dispensed until the PA process was complete, Dorr said. The team includes the equivalent of seven full-time employees.
Fairview pharmacy supports the program, Dorr said, because it promotes the pharmacy service to doctors and patients. Fairview is one of the state's largest operators of hospitals and clinics, but the pharmacy division is large, too, with 39 locations including a network of retail pharmacies.
The in-house service works well for physicians at both Fairview and the University of Minnesota Physicians, Dorr said, because the central PA team has access to electronic medical records that makes it easier to answer questions from the PBMs.
"We will manage the prior authorization whether the patient fills at Fairview or Walgreens or another pharmacy," Dorr said. "The real story [with the PA team] is the efficiencies that are gained and the education piece that is gained by having it all pop up right in front of your face in the electronic medical record. The doctor knows what's happening, and then the process itself moves forward a lot faster."
Christopher Snowbeck • 612-673-4744
