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Why Can't I Get My Prescription Filled

Electronic health records offer a function called CPOE *Computerized Order Entry" which provides an electronic means for ordering medications and tests within the hospital. EHRs also allow prescriptions to be sent to a pharmacy.  However many drugs require prior authorization (PA).

That has been a manual process. The provider is required to send a form detailing what medications have already been tried and failed due to ineffectiveness, side effects or a complication. The authorization is then sent manually from the health plan to the pharmacy manually.  The process is inefficient and is repeated many times a day, occupying time which can be better used caring for patients.

A critical process is still performed manually ten years after the implementation of the EHR. This arduous and repetitive process often causes the prescriber to write a prescription that may be less expensive even though it will be less effective to avoid the bureaucracy of requesting a PA.
Prior Authorizations (PAs) have become increasingly burdensome for providers — they contribute to 92 percent of care delays and an estimated 77 million are submitted manually each year. In fact, the process has become so burdensome that many physicians get fed up with the process end up writing for less-effective prescriptions because they know the preferred drug will require prior authorization.

Regardless of the decision, this is a problem that has yet to be resolved despite the development of new technology and software — such as electronic prior authorizations (ePAs) — that have tried to streamline the process. While these solutions have helped, they are temporary at best, as their lack of widespread adoption still leaves physicians and their staff responsible for the time and financial commitment associated with PAs.

What if there was a way to remove the responsibility from providers’ shoulders entirely? I believe there is, and it’s as simple as making prior authorizations a pharmacy responsibility.

Why should PAs be a pharmacy responsibility?

The answer is simple: they’re the pharmacy’s to lose.

There is no financial incentive for a provider to file a PA. Instead, they do so out of moral obligation to their patients (and because that’s the way it’s always been done, since providers are the only ones with access to the patient information needed to complete the PA). Pharmacies, on the other hand, have all the financial incentive to become principal participants in the process. After all, the faster a prescription is approved by an insurance company, the sooner (and more frequently) those prescriptions can get filled.

The problem is, most pharmacies don’t identify PAs as a financial incentive. The process can be time-consuming and tedious — as providers know well — so most pharmacies haven’t even considered it as an option. Of those who have, few choose to take on such a task, opting instead to let the system run its course and simply take whatever prescriptions come in organically. This leads not only to delays in patient care but also to alarmingly lengthy gaps between getting prescriptions filled. But the fact remains approvals (or denials) of PAs ultimately affect a pharmacy’s ability to bring in prescriptions and revenue, so pharmacies should be more proactive in participating with physicians in the care process.

Why hasn’t this been considered before?

The biggest roadblock to efficiently dealing with PAs is the pharmacy’s lack of access to relevant and necessary patient information. By default, providers have been assigned the responsibility for filing PAs simply because they have access to all the information required to submit them. Pharmacies, on the other hand, only have part of the information needed. Software companies like CoverMyMeds help to fill in some of the gaps, but PAs still ultimately find their way back to providers for missing patient information and submission. And since there’s no financial incentive for providers to complete them, PAs get put on the backburner, piling up until finally time is set aside to complete them.

What the industry ultimately needs is a solution that removes the burden from providers entirely, while still giving pharmacies secure and confidential access to the information they need from the get-go.

Pharmacies can do this by proactively coordinating with providers to obtain the information necessary to correctly and completely fill and submit a PA, perhaps through (read-only) access to the provider’s electronic medical records (EMR) system. Doing so creates a touchless system for providers that decreases downtime in the prescription-filling process and ultimately gets patients the best prescriptions, faster.

The Tufts Center for the Study of Drug Development most recently estimated the cost of bringing a new drug to pharmacy shelves at $2.7 billion. But that cost only increases when PAs enter the picture.

Physicians often hesitate to prescribe new drugs (even if they’re the best option) because of PA requirements, making it more difficult for a new medication to enter the market and for patients to get the prescriptions they need. By shifting the responsibility of PAs from providers to pharmacies, physicians can feel more confident in prescribing the medication they want the first time, making it easier for new medications to make it from shelves to homes, and ultimately driving healthcare costs down.

In the end, prior authorizations can never be a single party’s responsibility — a successful solution depends on the partnership of pharmacies and providers who work together for the benefit of patients. In doing so, pharmacies and providers can build stronger working relationships and, together, provide patients with a better quality of care.

The answer to your prior authorization problem is simpler than you think: Pharmacies and providers can build stronger working relationships and, together, provide patients with better quality of care.

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