Digitizing the prior authorization process

Electronic prior authorization (ePrior Authorization) has the potential to reduce the time to a drug approval decision, allowing plan members to start medication earlier, which can lead to better health outcomes, said TELUS Health’s Jason Kennedy, director of health business consulting, at Benefits Canada’s Face to Face Drug Plan Management Forum on December 9. He presented alongside Tara Liu, director of drug strategy at Canada Life.

Now, after establishing a more than 10-year track record in the United States and other jurisdictions, ePrior Authorization has arrived in Canada, launched last month by TELUS Health. But that’s far from the end of the story. Kennedy pointed out that realizing ePrior Authorization’s potential requires change management, adoption support, a commitment to learn from other markets, and technical and business process solutions. So, he asked, “How do we do this in such a way that the wins are greater than the effort?”

To be successful, he suggested that an ePrior Authorization strategy needs several pieces to fall into place. Intrusiveness for physicians, who are clearly a key stakeholder, must be minimized. The challenging area of plan member and physician consent must be navigated. Workflows must be made as frictionless as possible.

And, critically, criteria must be set to allow automated decision-making, and it must also be accepted that not all criteria can be managed digitally. “Perhaps it’s about how we find a balance to ensure we automate what we can to streamline the more common molecules, but also use that learning to evaluate the benefit of automation and the value of free-form tests in decision-making,” he said. A significant advantage of ePrior Authorization is that it can take care of easier-to-adjudicate claims, freeing up time to devote offline to more complex decisions.

Kennedy described the current paper-based prior authorization process for payers and reviewers as “a swivel chair process,” through which information is provided and reviewed on a form, a decision is made, and then that decision is communicated to the plan member. Even a simplified depiction of the process shows multiple hand-offs between the physician, plan member, pharmacist and insurer.

There can be a significant amount of duplicated effort as well during all the back and forth. However, Kennedy emphasized that some of this can be virtually eliminated using simple digital features such as mandatory fields (so critical data can’t be left out) and standardized outputs (to ensure all information is legible). After all, he said, “We have some anecdotal information that says anywhere from 5% to 10% of re-work is created from missing information or information you can’t read.”

Today, Kennedy said, “We have a landscape that has changed around us.” The pipeline of specialty molecules, which make up the majority of drugs in prior authorization, continues to grow. Complexity in treatment and costs has created a market for patient support programs, including patient navigation and reimbursement navigation. Specialists are increasingly involved in patient care, some practising in hospitals, clinics and other settings, and the number of physicians across Canada sits at about 90,000.

Integrating ePrior Authorization into an already complex system will take hard work, but the rewards can be significant. Digital data has the potential to unlock richer analytics and insights, improve decision-making and inform future plan design options. And, while prior authorization doesn’t tend to be top of mind for plan sponsors, it is an important risk mitigation solution that can both ensure medications are used appropriately and improve the plan member experience. Taking the process digital through ePrior Authorization can elevate prior authorization, streamlining the process to maximize its benefits.