The prior authorization process – a prerequisite for specialty medication therapy – is intended to ensure patients receive appropriate and effective treatment. However, it is one of many barriers to specialty medication access that can delay or prevent patients from starting therapy and create additional stress for patients and their caregivers.
Obtaining prior authorization is also time-consuming for providers. In 2013, one survey found doctors and nurses in a typical medical office spend around 14 hours each week on prior authorizations and appeals.1 This adds up for health systems. A study examining primary care practices estimated the prior authorization process costs up to $3,430 per physician annually.2
Clinic-Based Specialty Pharmacy Services Remove Barriers to Specialty Medication Access
Health systems can lessen the burden of prior authorizations on patients and providers by offering clinic-based specialty pharmacy services. At our partner health systems, pharmacy liaisons are embedded in specialty clinics to proactively manage prior authorizations. They also handle appeals, financial assistance applications, refill reminders, prescription deliveries, and more.
Being on-site helps in-clinic specialty pharmacy liaisons accelerate prior authorizations because they have direct access to patients’ care teams and medical records. This allows them to obtain information required for prior authorizations more quickly than external specialty pharmacies can. Because they are held accountable for providing exceptional, timely patient care, they are persistent about following-up with health plans – often checking in daily until approval is received.
Specialty Pharmacy Liaisons Go Above and Beyond for Patients
The pharmacy liaisons at our partner health systems also get to know patients personally. This pushes them to go above and beyond to help patients access medications even when prior authorization and appeals are denied. A recent story shared by a pharmacy liaison at a partner health system illustrates their dedication:
Shortly after we started partnering with one health system, I began supporting a patient with Hepatitis C. The patient and her care team had been trying to get approval for a specialty medication needed to treat her condition for over six months.
I quickly got involved to help the patient and her care team. My first step was to investigate the patient’s benefits. Through my research, I learned that her self-funded insurance plan had fibrosis level restrictions. This meant the insurance plan would only approve the medication once the patient’s liver damage reached a certain level.
Though I knew the patient’s insurance plan would not approve the medication, I still submitted a prior authorization and appeals to gather documentation needed to apply to the drug manufacturer’s patient assistance program. Unfortunately, because of the insurance plan’s fibrosis level restrictions, the drug manufacturer would not provide financial support.
After this, I began brainstorming other ways to help the patient access the medication. In partnership with the patient, I tried many things, including asking her company’s HR department and CEO to remove the fibrosis level restrictions.
Unfortunately, these attempts weren’t successful either. However, I never stopped looking for ways to help the patient access the medication and stayed up-to-date on eligibility criteria for her health plan and the drug manufacturer patient assistance program.
When the drug manufacturer eventually removed the fibrosis level restriction from its patient assistance program, I immediately reached out to the patient and helped resubmit an application to the patient assistance program. Shortly thereafter, she finally received approval and was able to begin her medication.
Health System Specialty Pharmacy Programs Benefit Providers Too
An on-site specialty pharmacy program also removes the administrative burden specialty medications create for doctors and nurses. This enables them to spend more time on face-to-face patient care. When in-clinic pharmacy liaisons started managing prior authorization and other administrative tasks associated with specialty medications, oncologists at one of our partner health systems gained 10 percent more capacity to devote to patient care.
Integrating specialty pharmacy services at your health system can remove barriers to specialty medication access helping patients access needed medications and boosting providers’ satisfaction. Click here to read another blog post about other ways an on-site specialty pharmacy program can improve your patients’ experiences and health outcomes. Or contact us directly to discuss your health system’s specialty pharmacy growth opportunity.
- Casalino LP, Nicholson S, Gans DN, et al. What does it cost physician practices to interact with health insurance plans?. Health Aff (Millwood). 2009;28(4):w533-43.
- Morley CP, Badolato DJ, Hickner J, Epling JW. The impact of prior authorization requirements on primary care physicians’ offices: report of two parallel network studies. J Am Board Fam Med. 2013;26(1):93-95.