Point-of-Care Partners Releases In-Depth Report Advising Healthcare…

ePrior Authorizations Real Benefits Report Cover

ePrior Authorizations Real Benefits Report

ePA is a key approach to ameliorating some of these unintended consequences through automation

Point-of-Care Partners, a health IT management consulting firm, today released a major and comprehensive report on ePrior Authorization (ePA). A powerful, automated, utilization management approach, ePA is designed to reduce the administrative burden of prior authorizations (PA) increasingly being used by payers that require providers to receive approvals before certain medications, devices, services, and procedures can be covered. The report is aimed at providing advice to payers, providers, life sciences companies, and the stakeholders supporting them. It will be especially valuable to aspirational and progressive payers and providers involved in value-and risk-based contracts, as well as organizations that are similarly challenged to improve patient safety while also containing rising costs.

One of the main drivers of PA is the rising use of expensive and complex specialty medications. Although only one percent of prescriptions are for specialty drugs, they account for 1/3 (rising to ½) of pharmacy plan costs, and many require a PA. These PAs are often completed via phone calls and faxes between the pharmacy, provider, and health plan. Manual processing is a time-consuming effort that leads to high administrative costs, the patient abandoning the prescription 37 percent of the time, and an increased time-to-therapy. Providers have been organized and vocal in their pushback against PAs, and in how ePA could help. Payers are starting to recognize the major investments they will need to make to address these concerns.

ePA is a major approach automating the PA process, thereby easing the burden of PAs and reigning in administrative costs while reducing time-to-therapy for patients from days/weeks to a few minutes. The most common adoption of ePA today takes place with drugs retrospectively, at the pharmacy. Prospective ePA, which would reduce costs and time to therapy even further, takes place at the time of ordering, but adoption has been disappointing for many reasons. Requirements for ePA that would apply to any treatment include accurate data that identifies if a PA is required, whether the treatment is covered by the pharmacy or the medical benefit, and the transparent and complete requirements for what information is needed based on history, evidence, and care plans to resolve the request. Transaction standards, interoperability technology for exchanging data, and workflow integration with EHRs and payer systems are among the most important areas for ePA advance, but each of these areas is a challenge.

To address these and many other ePA challenges, this report leverages Point-of-Care Partner’s unique perspective and relationship in the market with payers, providers, and their vendors. POCP’s experts drew on their extensive experience with ePA, ePrescribing, medication management, and transactions in support of value-based care together with industry interviews to craft this compelling report with a focus on:

  • Current market conditions and market drivers for ePA, including analysis of the differences of ePA adoption (and why ePA in many areas has stalled), opportunity, and return on investment between regular and specialty medications (and why they should be such a high focus), and between pharmacy vs medical benefit (and why they should come together).
  • Required ePA technical components, including integrated workflow vs portals, and interoperability/transaction standards, including the current and future use of X12 (and why the 278 has been a hinderance), National Council for Prescription Drug Programs (NCPDP) Script (and why it has been so successful), and evolving Health Level 7 (HL7) standards such as Fast Healthcare Interoperability Resources (FHIR) (which shows substantial promise), and their relationship to real-time benefit check.
  • An ePA maturity model to help advise organizations where they are and what they need to do to progress to the fourth stage, the ideal ePA; adoption challenges of ePA; multiple ePA cases studies; and lessons learned.
  • ePA vendor profiles featuring the most comprehensive list ever compiled of more than 40 representative and leading ePA ecosystem vendors segmented by their primary ePA focus into seven categories: specialty/intermediary ePA, payer and utilization management (UM), ePrescribing network, clinical content, PBM, EHR, and Revenue Cycle Management (RCM).
  • A future ePA outlook, including the impact of artificial intelligence/natural language processing, use of blockchain, which regulations will have the greatest impact (including views on proposed critical CMS and ONC regulations), and what it will take to reach a seamless future of provider/payer convergence.
  • Specific, actionable advice for payers, providers, converged value-based entities, vendors, and other key stakeholders to drive ePA success.

“Prior authorization, while a powerful tool to achieve the goals of improving patient safety and containing costs, often comes with unintended consequences like administrative burdens for payers and providers in addition to drastically extending the time a patient has to wait for approval in order to start physician-prescribed therapy,” said Ken Kleinberg, Practice Lead, Innovative Technologies, Point-of-Care Partners. “ePA is a key approach to ameliorating some of these unintended consequences through automation. Our goal with this report -- our most extensive ever (with 40+ diagrams and tables, and 90+ references) -- is to offer healthcare stakeholders an independent analysis of the market, realistic maturity models, and a profile of what vendors and service companies are currently doing around ePA so they can arm themselves with the information needed to plan strategically and meet their goals.”

Payers, providers, life science companies, and vendors interested in learning more are invited to register for an informational webinar that will be held on May 29, 2019 at noon. For more information about the report, please visit our website. For direct inquiries about the report contact Ken Kleinberg ken.kleinberg(at)pocp(dot)com.

About Point-of-Care Partners
Point-of-Care Partners is a health IT management consulting firm. Having been at the forefront of ePA for more than a decade, the firm’s consultants have led NCPDP’s Prior Authorization Workflow-to-Transactions Task Group since 2005; led efforts to create processes around the HIPAA-named standard for ePA, the X12N 278; is program managing efforts to leverage HL7’s FHIR in support of ePA, and has advised the Federal government on ways to enhance adoption of ePA. To learn more about Point-of-Care Partners’ ePA expertise, visit its website at http://www.pocp.com. If you’re interested in POCP helping your company understand the changing healthcare landscape and implement effective ePA or medication management strategies, contact info(at)pocp(dot)com.

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