Taking Specialty Prior Authorization From 5 Days to 5 Minutes

Today’s guest post comes from Scott Pribyl, CEO of SamplifyRx. Scott discusses RapidPA Score™—an intriguing scoring system for specialty drug prior authorizations. He also reviews the benefits of a cloud-based tool that allows for near real-time prior authorization (NRTPA) approvals. Interesting concept. Check it out.

Scott will be at the 2015 Armada Specialty Pharmacy Summit in Las Vegas next week. Email him at scott@samplifyrx.com to learn more about SamplifyRx’s new, cloud-based PA solution or to set up a meeting.

BTW, Lew Morris, former Chief Counsel to the Inspector General, analyzed how the SamplifyRx solution improves a manufacturer's compliance with OIG guidance for copayment coupons. Click here to download Lew's analysis.

Taking Specialty Prior Authorization From 5 Days to 5 Minutes
By Scott Pribyl, CEO, SamplifyRx

Ask any patient diagnosed with a severe or chronic disease which prior authorization (PA) approval time they prefer:

5 days or 5 minutes?

It’s an easy decision for any patient. Being diagnosed on a Monday with a life-changing disease and waiting until Friday for approval of a miracle drug is unacceptable.

Advances in e-prescriptions (eRx) and electronic prior authorizations (ePA) have facilitated the PA process for 99% of the general population. The remaining 1% of patients, however, take specialty drugs. In 2014, specialty drugs accounted for 31% of the total pharmacy benefit spending. Their share is projected to be 44% by 2018. (source)

Patients taking specialty therapies are subjected to the time-consuming and inefficient clinical decision approval process that takes 3-5 days.

Patient Journey

The chart below illustrates the current process for PA of a specialty drug prescription. Current delays in approval cause disappointment and frustration. The specialty industry needs to move to near real-time prior authorization (NRTPA) approvals for patients.

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Consumers would never tolerate waiting 5 days for a bank to approve a loan on a car. So, the automobile industry took the approval process from 5 days down to minutes with the use of the FICO score. A complex and cumbersome workflow was made more efficient and effective with the implementation of a new solution. The specialty PA workflow can be improved in the same way.

The Benefits of Cloud-Based Hubs

When looking at potential healthcare technology solutions, there are two main avenues for the exchange of medical information:

• Integrate with EHR and eRx software (interoperability)
• Create a cloud-based hub

The re-designed specialty PA solution starts with a neutral, cloud-based software portal that connects every participant in the specialty workflow. These connections are illustrated below.

[Click to Enlarge]

Today, interoperability can be limited due to implementation costs, time, and contractual constraints. A recent ONC report examined allegations that some health care providers and health IT developers are engaging in “information blocking,” deliberately interfering with the exchange or use of electronic health information.

The NCPDP formats for eRx and ePA provide tremendous value for interoperability. While NCPDP has advanced and transformed prior authorizations, it still requires the prescriber, specialty pharmacy, and PBM to be fully integrated.

ePA pharmacy benefit and claims management is not enough. The specialty process also requires evidence-based document management, outcomes decisions, and coordination of patient support programs.

Utilizing a cloud-based system provides numerous advantages over direct integration:

• All data can be queried and shared regardless of ePA or HER
• Notification-driven communication versus faxes or encrypted emails
• HIPAA-compliant, seamless document sharing
• Data readily available; not in independent silos
• Patient support programs remain in queue until the PA is approved (OIG and CMS compliance)
• No hardware to install

Eliminate the PDF Library and Use the Dynamic PA

At least $23 billion—equal to 10% of prescribers’ revenues—is used for interaction with health plans. (source) A specialty physician’s office typically has one to three 3 full-time employees who are dedicated to prior authorizations. SamplifyRx estimates that the current system results in an astounding 4 quintillion potential workflow options. (Check my math below.)

[Click to Enlarge]

Prescribers are ready for a more efficient solution.

We propose a new process:

• One order screen
• One customizable dynamic PA
• Direct connect between prescriber, specialty pharmacy, and PBM
• Near real-time prior authorization approvals

Using this approach, the time to complete all paperwork and receive approval can occur before the patient leaves the prescriber’s office.

Quantify the Subjective—RapidPA Score™

If the auto industry’s lenders can use FICO as a cumulative historical scoring system, then why can’t the specialty industry use a similar aggregator?

[Click to Enlarge]
(Loremify is a fictional drug)

SamplifyRx has created RapidPA Score™—the first scoring system for specialty prior authorizations. By utilizing a customizable, proprietary algorithm, a PBM can expedite the PA approval process by quantifying the decision support questions. As a result, the PBM can now make informed decisions automatically or manually.

RapidPA Score™ allows a PBM to set its approval criteria within the dynamic PA. If a patient’s score falls within a pre-defined range and their criteria have been met, the patient should be immediately approved.

Conversely, if the RapidPA Score™ falls below the pre-defined threshold, the PBM knows that the patient is not eligible immediately. The prescriber can then make step therapy modifications before the patient leaves.

In the case of a mid-range RapidPA Score™ the clinical pharmacist has immediate access to all supporting documentation in a centralized electronic portal.

RapidPA Score™ gives the patient an actionable decision before they leave the physician’s office—taking the process from 5 days to 5 minutes.

Conclusion

Utilizing near real-time prior authorization clinical approvals, like those provided by SamplifyRx’s RapidPA Score™, improves the entire specialty PA experience:

• The patient and physician satisfaction improves

• The PBM manages specialty drug spend with evidence-based decision support

• The specialty pharmacy coordinates delivery of specialty drug and patient support programs to patient’s home within 24 hours of patient leaving doctor’s office

This new specialty workflow also solves other problems, like copayment coupons compliance—a major concern addressed in a recent OIG report. Lew Morris, former Chief Counsel to the Inspector General, analyzed how the SamplifyRx solution improves a manufacturer's compliance with OIG guidance for copayment coupons. Click here to download his analysis.

If you have questions about Samplify Rx’s new, cloud-based PA solution, email Scott Pribyl, CEO of SamplifyRx.