By Taruja Karmarkar, PhD, MHS, NPC/Duke-Margolis Health Policy Fellow
The Journal of Managed Care & Specialty Pharmacy earlier this month published the proceedings from the Academy of Managed Care Pharmacy (AMCP) Partnership Forum, “Optimizing Prior Authorization for Appropriate Medication Selection,” which focused on the challenges of current prior authorization and step therapy programs, approaches to improve these processes for patient care, and reviewed current legislative activities underway to reform prior authorization (PA) and step therapy (ST).
Prior authorization and step therapy are common tools used by plans to manage drug utilization. The use of step therapy, specifically, is growing as Medicare Advantage plans can now use step therapy to manage Part B drugs and the Centers for Medicare and Medicaid Services (CMS) is now considering using step therapy for Medicare fee-for-service plans more frequently. Despite its growing use, many provider and patient groups have voiced concerns regarding the impact of utilization management on access to care and have developed guiding practices for the use of these tools. Over 30 states have approved legislative reforms for step therapy to ensure patient protections throughout these processes. However, little formal guidance exists on ways to improve upon these current approaches to utilization management (UM).
That’s why AMCP brought together Forum participants to develop a set of recommendations to improve these processes for the patient, provider, pharmacist and health system. During a daylong meeting in June 2019, Forum participants used case studies, real-world examples and AMCP’s PA and Utilization Management Concepts in Managed Care Pharmacy as the basis for their discussion. They identified challenges in the use of PA and ST as well as opportunities and solutions to improve the use of these tools.
Importantly, participants noted that a key goal should be increasing transparency between the different stakeholders, especially for patients regarding a plan’s UM requirements, as well as the appeals and exceptions process. They also recommended the routine evaluation of PA criteria as an important component of the implementation process. Routine evaluations can provide plans with an opportunity to update PA requirements while ensuring evidence-based prescribing.
Forum participants also noted that patients, providers and pharmacists face significant administrative burdens because of ST and UM and recommended several ways to address it. One way is by leveraging advances in health information technology, such as expanding the use of electronic prior authorization (ePA), and automating certain processes. Along with clinical decision support tools, evolving data systems and platforms can help ease transitions along the care continuum, including obtaining the initial prescription, requesting exceptions or appeals, and making the final adjudication regarding access to a prescription. Participants, however, identified the current lack of interoperability across data systems as a challenge to achieving this best practice.
Some of the Forum’s recommendations for improvements in PA and ST will require legislative actions at the state or federal levels. Current state and federal legislation has focused on ensuring that PA and ST include adequate flexibility for unique patient populations and clearly communicate the opportunity for submitting an exception or appeal request. While important steps for patient protections, participants cautioned that legislative solutions are often difficult to achieve.
Overall, Forum participants highlighted that while the needs of multiple stakeholders must be considered in order to implement these proposed solutions, the primary focus should be delivering timely, appropriate and evidence-based care to patients.
Research conducted by the National Pharmaceutical Council (NPC) and the Center for Evaluation of Value and Risk in Health at Tufts Medical Center has demonstrated how common step therapy is and the burden it can place on patients. Ongoing research by NPC has shown that, similar to the AMCP forum participants, stakeholders may disagree on when it is used, but agree on how step therapy should be developed, implemented, communicated and evaluated.
NPC was among the sponsors of the Forum. Learn more about NPC’s ongoing efforts to support evidence-based access to medicines.