1
|
Sedghi T, Gronbeck C, Aiudi DA, Grant-Kels JM. Assessing the ethics of prior authorization denials and step therapy policies in dermatology. J Am Acad Dermatol 2024; 90:877-878. [PMID: 36822353 DOI: 10.1016/j.jaad.2023.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 01/17/2023] [Accepted: 02/09/2023] [Indexed: 02/24/2023]
Affiliation(s)
- Tannaz Sedghi
- University of Connecticut School of Medicine, Farmington, Connecticut
| | - Christian Gronbeck
- Department of Dermatology, University of Connecticut Health Center, Farmington, Connecticut
| | - Donna A Aiudi
- Department of Dermatology, University of Connecticut Health Center, Farmington, Connecticut
| | - Jane M Grant-Kels
- Department of Dermatology, University of Connecticut Health Center, Farmington, Connecticut; Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida.
| |
Collapse
|
2
|
Kyle MA, Keating NL. Prior Authorization and Association With Delayed or Discontinued Prescription Fills. J Clin Oncol 2024; 42:951-960. [PMID: 38086013 PMCID: PMC10927330 DOI: 10.1200/jco.23.01693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 09/29/2023] [Accepted: 10/13/2023] [Indexed: 03/08/2024] Open
Abstract
PURPOSE Prior authorization requirements are increasing but little is known about their effects on access to care. We examined the association of a new prior authorization policy with delayed or discontinued prescription fills for oral anticancer drugs among Medicare Part D beneficiaries. METHODS Using Medicare part D claims data from 2010 to 2020, we studied beneficiaries regularly filling one of 11 oral anticancer drugs, defined as three 30-day fills in 120 days preceding the plan's prior authorization policy change on that drug and continuously enrolled in the same plan for 120 days before and after the policy change at the start of a new year. The control group consisted of beneficiaries meeting the same utilization criteria, but who were enrolled in plans at the same time that did not implement a prior authorization policy change. The outcomes of interest were discontinuation of the drug within 120 days (analyzed with regression analyses) and time (in days) to next fill after a prior authorization policy change (analyzed using a quasi-experimental difference-in-differences event study). RESULTS The introduction of a new prior authorization on an established drug increased the odds of discontinuation within 120 days (adjusted odds ratio, 7.1 [95% CI, 6.0 to 8.5]; P < .001) and increased time to next fill by 9.7 days (95% CI, 8.2 to 11.2; P < .001), relative to patients whose plans did not have a prior authorization policy change. CONCLUSION Introduction of a new prior authorization policy on an established drug regimen is associated with increased probability of discontinued and delayed care. For some conditions, this may represent a clinically consequential barrier to access. Waiving prior authorization for patients already established on a drug may improve adherence.
Collapse
Affiliation(s)
- Michael Anne Kyle
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Nancy L. Keating
- Department of Health Care Policy, Harvard Medical School, Boston, MA
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA
| |
Collapse
|
3
|
Gupta R, Fein J, Newhouse JP, Schwartz AL. Comparison of prior authorization across insurers: cross sectional evidence from Medicare Advantage. BMJ 2024; 384:e077797. [PMID: 38453187 PMCID: PMC10919211 DOI: 10.1136/bmj-2023-077797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/13/2024] [Indexed: 03/09/2024]
Abstract
OBJECTIVE To measure and compare the scope of US insurers' policies for prior authorization (PA), a process by which insurers assess the necessity of planned medical care, and to quantify differences in PA across insurers, physician specialties, and clinical service categories. DESIGN Cross sectional analysis. SETTING PA policies for five insurers serving most of the beneficiaries covered by privately administered Medicare Advantage in the US, 2021, as applied to utilization patterns observed in Medicare Part B. PARTICIPANTS 30 540 086 beneficiaries in traditional Medicare Part B. MAIN OUTCOME MEASURES Proportions of government administered traditional Medicare Part B spending and utilization that would have required PA according to Medicare Advantage insurer rules. RESULTS The insurers required PA for 944 to 2971 of the 14 130 clinical services (median 1899; weighted mean 1429) constituting 17% to 33% of Part B spending (median 28%; weighted mean 23%) and 9% to 41% of Part B utilization (median 22%; weighted mean 18%). 40% of spending ($57bn; £45bn; €53bn) and 48% of service utilization would have required PA by at least one insurer; 12% of spending and 6% of utilization would have required PA by all insurers. 93% of Part B medication spending, or 74% of medication use, would have required PA by at least one Medicare Advantage insurer. For all Medicare Advantage insurers, hematology and oncology drugs represented the largest proportion of PA spending (range 27-34%; median 33%; weighted mean 30%). PA rates varied widely across specialties. CONCLUSION PA policies varied substantially across private insurers in the US. Despite limited consensus, all insurers required PA extensively, particularly for physician administered medications. These findings indicate substantial differences in coverage policies between government administered and privately administered Medicare. The results may inform ongoing efforts to focus PA more effectively on low value services and reduce administrative burdens for clinicians and patients.
Collapse
Affiliation(s)
- Ravi Gupta
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Jay Fein
- Medidata Solutions, New York, NY, USA
| | - Joseph P Newhouse
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
- Department of Health Policy and Management, Harvard TH Chan School of Public Health, Boston, MA, USA
- Harvard Kennedy School, Cambridge, MA, USA
- National Bureau of Economic Research, Cambridge, MA, USA
| | - Aaron L Schwartz
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Michael J Crescenz VA Medical Center, Philadelphia, PA, USA
| |
Collapse
|
4
|
Neprash HT, Mulcahy JF, Golberstein E. The extent and growth of prior authorization in Medicare Advantage. Am J Manag Care 2024; 30:e85-e92. [PMID: 38457827 DOI: 10.37765/ajmc.2024.89519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/10/2024]
Abstract
OBJECTIVES To assess trends in the use of prior authorization requirements among Medicare Advantage (MA) plans. STUDY DESIGN Descriptive quantitative analysis. METHODS Data were from the CMS MA benefit and enrollment files for 2009-2019, supplemented with area-level data on demographic and provider market characteristics. For each service category, we calculated the annual share of MA enrollees in plans requiring at least some prior authorization and plotted trends over time. We mapped the county-level share of MA enrollees exposed to prior authorization in 2009 vs 2019. We quantified the association between local share of MA enrollees exposed to prior authorization and characteristics of that county in the same year. Finally, we plotted the share of MA enrollees exposed to prior authorization requirements over time for the 6 largest MA carriers. RESULTS From 2009 to 2019, the share of MA enrollees in plans requiring prior authorization for any service remained stable. By service category, the share of MA enrollees exposed to prior authorization ranged from 30.7% (physician specialist services) to 72.2% (durable medical equipment) in 2019, with most service categories requiring prior authorization more often over time. Several area-level demographic and provider market characteristics were associated with prior authorization requirements, but these associations weakened over time. The use of prior authorization varied widely across plans. CONCLUSIONS In 2019, roughly 3 in 4 MA enrollees were in a plan requiring prior authorization. Service-level, area-level, and carrier-level patterns suggest a wide range of approaches to prior authorization requirements.
Collapse
Affiliation(s)
- Hannah T Neprash
- Division of Health Policy and Management, School of Public Health, University of Minnesota, 420 Delaware St SE, MMC 729, Minneapolis, MN 55455.
| | | | | |
Collapse
|
5
|
Abstract
This essay describes the author’s experience with denial of prior authorization for imaging to complete cancer staging.
Collapse
Affiliation(s)
- Arman A Shahriar
- Department of Internal Medicine, The University of Chicago Medical Center, Chicago, Illinois
| |
Collapse
|
6
|
Harris E. CMS: New Rule Will Improve Efficiency and Speed of Prior Authorization. JAMA 2024; 331:554. [PMID: 38294843 DOI: 10.1001/jama.2023.28336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
|
7
|
Rao V, Dharia I, Gibilisco J, Kirelik D, Baumgartner S, Negreira K, Chawla K, Dave J, Kallus S, Belfaqeeh OA, Borum ML. Delay in prior authorization of biologic therapy: Another possible cause of healthcare disparity in IBD patients. J Natl Med Assoc 2024; 116:13-15. [PMID: 38036315 DOI: 10.1016/j.jnma.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 10/05/2021] [Accepted: 09/30/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Biologics, a mainstay in inflammatory bowel disease (IBD) treatment, typically require prior authorization from insurance companies. Multiple studies show that African Americans are less likely to be prescribed biologics. The prior authorization process may perpetuate disparities in healthcare. This study evaluated the approval time for biologics in IBD. METHODS A chart review of IBD patients seen in a university gastroenterology clinic over 5 years was performed. Patient gender, race, IBD subtype, biologic use, and insurance type were recorded. Insurance type was classified as private or public (Medicaid or Medicare). Biologic agents evaluated included infliximab, adalimumab, vedolizumab and ustekinumab. Length of time to approval (TTA) and length of time to first infusion or administration (TFI) were recorded. Analysis was performed using t-testing, Fisher's exact testing, and ANOVA with significance set at p<0.05. The study was IRB approved. RESULTS 458 charts were analyzed. 66 patients were being treated with a biologic. 42 had private insurance, 16 Medicaid and 8 Medicare. 37 patients had ulcerative colitis, 27 Crohn's disease, and 2 indeterminate colitis. There were 38 men and 28 women. 32 patients were white, 26 African American, 1 Asian, 5 other, and 2 declined identification. Average TTA was 30.5 days (range 1-145) and average TFI was 45.3 days (range 2-166). African Americans were more often on public insurance compared to whites (p=0.0001). Crohn's disease compared to ulcerative colitis patients were more often on public insurance (p=0.017). Significantly more private compared to public insurance patients were on infliximab (p=0.001). Medicaid and Medicare patients had significantly longer mean TTAs than private insurance patients (49.1 and 52.7 vs 19.4 days, p=0.007). African Americans had significantly longer mean TTA compared to whites (45.9 vs 24.8 days, p=0.044). Crohn's disease compared to ulcerative colitis patients had significantly longer mean TTA (39.7 vs 21.8 days, p=0.050). DISCUSSION This study shows that prior authorization for biologic therapy was longer for African Americans. Patients on public insurance also tend to have a longer TTA, and more African Americans were on public insurance compared to White patients in this study which may explain the difference in biologic access for African Americans.
Collapse
Affiliation(s)
- Vinay Rao
- Gastroenterology and Liver Diseases, Department of Medicine, The George Washington University, Washington, DC
| | - Ishaan Dharia
- Department of Medicine, The Mount Sinai Hospital, New York, NY
| | | | - Danielle Kirelik
- Division of General Internal Medicine, University of Colorado, Aurora, CO
| | - Scott Baumgartner
- Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburg, PA
| | - Katherine Negreira
- Department of Medicine, University of Miami, Jackson Memorial Health, Miami, FL
| | - Karan Chawla
- Division of Gastroenterology and Nutrition, Department of Medicine, Loyola University, Maywood, IL
| | - Jenny Dave
- Department of Gastroenterology and Hepatology, Department of Medicine, Mount Sinai Morningside-West, New York, NY
| | - Samuel Kallus
- Capital Digestive Care, Chevy Chase Office, Chevy Chase, MD
| | | | - Marie L Borum
- Gastroenterology and Liver Diseases, Department of Medicine, The George Washington University, Washington, DC.
| |
Collapse
|
8
|
Constant BD, Albenberg L, Mitchel EB, De Zoeten EF, Clapp JT, Scott FI. Prior Authorizations Delay Therapy, Impact Decision-making, and Lead to Adverse Events in Inflammatory Bowel Disease: 2022 Provider Survey. Clin Gastroenterol Hepatol 2024; 22:423-426. [PMID: 37394025 DOI: 10.1016/j.cgh.2023.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 06/12/2023] [Accepted: 06/21/2023] [Indexed: 07/04/2023]
Affiliation(s)
- Brad D Constant
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Lindsey Albenberg
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Elana B Mitchel
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Edwin F De Zoeten
- Division of Gastroenterology and Hepatology, Department of Pediatrics, University of Colorado Anschutz School of Medicine, Children's Hospital Colorado, Digestive Health Institute, Aurora, Colorado
| | - Justin T Clapp
- Department of Anesthesiology and Critical Care, Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Frank I Scott
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| |
Collapse
|
9
|
Andrews CM, Westlake MA, Abraham AJ, Grogan CM, Harris SJ, Jehan S. Medicaid Managed Care Prior Authorization For Buprenorphine Tied To State Partisanship And Health Plan Profit Status, 2018. Health Aff (Millwood) 2024; 43:55-63. [PMID: 38190595 DOI: 10.1377/hlthaff.2023.00288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
Buprenorphine is among the most effective drugs for treating opioid use disorder, yet only a quarter of Americans who need it receive it. Requiring prior authorization has been identified as an important barrier to buprenorphine access. However, the practice remains widespread in Medicaid-the largest insurer of Americans with opioid use disorder. In this study, we examined how prior authorization for buprenorphine is related to plan structure and state political environment, using data on all 266 comprehensive Medicaid managed care plans active in 2018. We found substantial variation in prior authorization use across states, with all plans requiring prior authorization in eleven states and no plans requiring it in thirteen other states. We found that for-profit plans and those located in Republican states were more likely to impose prior authorization policies. Our findings suggest that managed care plans' decisions regarding use of prior authorization may be shaped by internal pressures to control costs, as well as by differing partisan stances regarding the need to prevent criminal diversion of buprenorphine.
Collapse
Affiliation(s)
- Christina M Andrews
- Christina M. Andrews , University of South Carolina, Columbia, South Carolina
| | | | | | | | | | | |
Collapse
|
10
|
Parad A, Gallo C. Easing Prior Authorization for Advanced Imaging. Fam Pract Manag 2024; 31:7-11. [PMID: 38194300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
|
11
|
Marcus BS, Bansal N, Saef J, Fink C, Patel A, Shaffer KD, Mayer JE, Johnson JN, Shaffer K, Chowdhury D. Burden with No Benefit: Prior Authorization in Congenital Cardiology. Pediatr Cardiol 2024; 45:100-106. [PMID: 37750969 PMCID: PMC10776488 DOI: 10.1007/s00246-023-03255-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 07/25/2023] [Indexed: 09/27/2023]
Abstract
Prior authorization is a process that health insurance companies use to determine if a patient's health insurance will cover certain medical treatments, procedures, or medications. Prior authorization requests are common in adult congenital and pediatric cardiology (ACPC) due to need for advanced diagnostics, complex procedures, disease-specific medications, and the heterogeneity of the ACPC population. Prior authorizations in ACPC are rarely denied, but nonetheless, they are often accompanied by significant administrative burden on clinical care teams and delays in patient care. Prior authorizations have been implicated in worsening care inequities. The prior authorization process is insurer specific with differences between commercial and public insurers. Prior authorization rejections were previously found to be more common for women, racial minorities, those with low education, and in low-income groups. Prior authorization unduly burdens routine diagnostics, routine interventional and surgical procedures, and routine cardiac specific medication use in the ACPC population. This manuscript highlights the burdens of prior authorization and advocates for the elimination of prior authorization for ACPC patients.
Collapse
Affiliation(s)
- Brian S Marcus
- Pediatric Cardiology, Yale School of Medicine, 205 Church Street, New Haven, CT, USA.
- Pediatric Critical Care, The Medical College of Wisconsin, Milwaukee, United States.
| | - Neha Bansal
- Pediatric Cardiology, Mount Sinai Kravis Children's Hospital, New York, NY, USA
| | - Joshua Saef
- Philadelphia Adult Congenital Heart Center, University of Pennsylvania, Philadelphia, PA, USA
- Heart Institute, Joe DiMaggio Childrens Hospital, Hollywood, Florida, USA
| | - Christina Fink
- Childrens Institute Department of Heart, Vascular & Thoracic, Division of Cardiology & Cardiovascular Medicine, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
| | - Angira Patel
- Ann & Robert H. Lurie Childrens Hospital, Chicago, IL, USA
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Katherine D Shaffer
- Texas Tech University Health Sciences Center, Jerry H. Hodge School of Pharmacy, Abilene, TX, USA
| | - John E Mayer
- Department of Cardiac Surgery, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - Jonathan N Johnson
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kenneth Shaffer
- Dell Medical School, University of Texas, Austin, TX, USA
- Pediatric and Congenital Cardiology Associates / Pediatrix Cardiology, Austin, TX, USA
| | - Devyani Chowdhury
- Nemours Cardiac Center, Wilmington, DE, USA
- Cardiology Care for Children, Lancaster, PA, USA
| |
Collapse
|
12
|
Lichtenstein MR, Beauchemin MP, Raghunathan R, Lee S, Doshi SD, Law C, Accordino MK, Elkin EB, Wright JD, Hershman DL. Association Between Copayment Assistance, Insurance Type, Prior Authorization, and Time to Receipt of Oral Anticancer Drugs. JCO Oncol Pract 2024; 20:85-92. [PMID: 38033273 PMCID: PMC10827292 DOI: 10.1200/op.23.00205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 09/06/2023] [Accepted: 09/19/2023] [Indexed: 12/02/2023] Open
Abstract
PURPOSE Oral anticancer drugs (OACDs) have become increasingly prevalent over the past decade. OACD prescriptions require coordination between payers and providers, which can delay drug receipt. We examined the association between insurance type, pursuit of copayment assistance, pursuit of prior authorization (PA), and time to receipt (TTR) for new OACD prescriptions. METHODS We prospectively collected data on new OACD prescriptions for adult oncology patients from January 1, 2018, to December 31, 2019, including demographic and clinical characteristics, insurance type, and pursuit of PA and copayment assistance. TTR was defined as the number of days from prescription to OACD receipt. We summarized TTR using cumulative incidence and compared TTR by insurance type, pursuit of copayment assistance, and PA activity using the log-rank test. RESULTS Our cohort of 1,024 patients was 53% male, and 40% were younger than 65. Twenty-six percent had commercial insurance only, 16% had Medicaid only, and 59% had Medicare with or without additional insurance. Eighty-six percent of prescriptions were successfully received. Across all prescriptions, 69% involved PA activity, and 21% involved the copayment assistance process. In unadjusted analyses, prescriptions involving the copayment assistance process had longer TTR compared with those not involving assistance (log-rank P value = .005) and OACDs covered by Medicare/commercial insurance had a longer TTR compared with Medicaid (log-rank P value = .006). The PA process was not associated with TTR (log-rank P value = .124). CONCLUSION The process for obtaining OACDs is complex. The copayment assistance process and Medicare/commercial insurance are associated with delayed TTR. New policies are needed to reduce time to OACD receipt.
Collapse
Affiliation(s)
- Morgan R.L. Lichtenstein
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY
- Division of Hematology/Oncology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Melissa P. Beauchemin
- Division of Hematology/Oncology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
- School of Nursing, Columbia University Irving Medical Center, New York, NY
| | - Rohit Raghunathan
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY
| | - Shing Lee
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY
- Mailman School of Public Health, Columbia University Irving Medical Center, New York, NY
| | - Sahil D. Doshi
- Division of Medical Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Cynthia Law
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY
| | - Melissa K. Accordino
- Division of Hematology/Oncology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
- School of Nursing, Columbia University Irving Medical Center, New York, NY
| | - Elena B. Elkin
- Mailman School of Public Health, Columbia University Irving Medical Center, New York, NY
| | - Jason D. Wright
- Division of Hematology/Oncology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY
| | - Dawn L. Hershman
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY
- Division of Hematology/Oncology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
- Mailman School of Public Health, Columbia University Irving Medical Center, New York, NY
| |
Collapse
|
13
|
Busis NA, Khokhar B, Callaghan BC. Streamlining Prior Authorization to Improve Care. JAMA Neurol 2024; 81:5-6. [PMID: 37983023 DOI: 10.1001/jamaneurol.2023.4324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
This Viewpoint addresses the challenges of prior authorization: decreased access, delayed care, decreased patient satisfaction and outcomes, and increased clinician burnout.
Collapse
Affiliation(s)
- Neil A Busis
- Department of Neurology, New York University Grossman School of Medicine, New York
| | - Babar Khokhar
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - Brian C Callaghan
- Department of Neurology, University of Michigan School of Medicine, Ann Arbor
| |
Collapse
|
14
|
Andraka-Christou B, Golan O, Totaram R, Ohama M, Saloner B, Gordon AJ, Stein BD. Prior authorization restrictions on medications for opioid use disorder: trends in state laws from 2005 to 2019. Ann Med 2023; 55:514-520. [PMID: 36724766 PMCID: PMC9897778 DOI: 10.1080/07853890.2023.2171107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
RESEARCH OBJECTIVE Medications for opioid use disorder (MOUDs) - including methadone, buprenorphine, and naltrexone - are the most effective treatments for opioid use disorder (OUD). Historically, insurers have required prior authorization for MOUD, but prior authorization is often reported as a key barrier to MOUD prescribing. Some states have passed laws prohibiting MOUD prior authorization requirements. We sought to identify the frequency of MOUD prior authorization prohibitions in state laws and to categorize types of prohibitions. METHODS We searched for regulations and statutes present in all U.S. states and Washington DC between 2005 and 2019 using MOUD-related terms in Westlaw legal software. In qualitative software, we coded laws discussing MOUD prior authorization using template analysis - a mixed deductive/inductive approach. Finally, we used coded laws to identify frequencies of states with prior authorization prohibitions, including changes over time. RESULTS No states had laws prohibiting MOUD prior authorization between 2005 and 2015, with the first prohibition appearing in 2016. By 2019, fifteen states had MOUD prior authorization prohibitions. States varied significantly in their approach to prohibiting MOUD prior authorization. In 2019, it was more common for states to have MOUD prior authorization prohibitions applying to all insurers (n = 10 states) than to only Medicaid (n = 7 states) or only non-Medicaid insurers (n = 1 state). In 2019, general prior authorization prohibitions (n = 10 states) were more common than prohibitions only applicable to medications on the formulary, prohibitions only applicable to medications on the preferred drug list, prohibitions only applicable during the first 5 days of treatment, and prohibitions only applicable during the first 30 days of treatment. CONCLUSIONS The number of states with an MOUD prior authorization law prohibition increased in recent years. Such laws could help expand access to life-saving OUD treatments by making it easier for clinicians to prescribe MOUD.KEY MESSAGESNo states had MOUD prior authorization prohibitions between 2005 and 2015 in state statutes or regulations, and only one state had such a prohibition in 2016.By 2019, fifteen states had an MOUD prior authorization prohibition law.States varied significantly in their approach to prohibiting MOUD prior authorization, including with respect to the insurer type, duration of the prohibition, and applicable medication.
Collapse
Affiliation(s)
- Barbara Andraka-Christou
- School of Global Health Management and Informatics, University of Central Florida, Orlando, FL, USA
- Department of Internal Medicine (Secondary Joint Appointment), University of Central Florida, Orlando, FL, USA
- CONTACT Barbara Andraka-Christou School of Global Health Management and Informatics, University of Central Florida, 525 W Livingston Street, Suite 401, Orlando, 32801FL, USA
| | - Olivia Golan
- School of Public Health, Georgia State University, Atlanta, GA, USA
| | - Rachel Totaram
- School of Global Health Management and Informatics, University of Central Florida, Orlando, FL, USA
| | - Maggie Ohama
- The Cardiac and Vascular Institute, Gainesville, FL, USA
| | - Brendan Saloner
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Adam J. Gordon
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | | |
Collapse
|
15
|
Omar D, Brown-Korsah JB, Taylor SC, Mollanazara N. Prior Authorization Timeliness and Success At a Single Center Centralized Pharmacy. J Drugs Dermatol 2023; 22:1233-1234. [PMID: 38051849 DOI: 10.36849/jdd.7246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
|
16
|
Constant BD, Scott FI. The PA System: Is Prior Authorization for Dose Escalation of IBD Biologic Therapy a Tolerable Alternative or a Perpetual Annoyance? Dig Dis Sci 2023; 68:4279-4281. [PMID: 37792128 DOI: 10.1007/s10620-023-08100-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 08/26/2023] [Indexed: 10/05/2023]
Affiliation(s)
- Brad D Constant
- Department of Pediatrics, University of Colorado School of Medicine, Digestive Health Institute, Children's Hospital Colorado, Aurora, CO, USA.
| | - Frank I Scott
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| |
Collapse
|
17
|
Harrison MB. Prior Authorization. Neurology 2023; 101:905-906. [PMID: 37648531 PMCID: PMC10662982 DOI: 10.1212/wnl.0000000000207790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 07/06/2023] [Indexed: 09/01/2023] Open
|
18
|
McManus KA, Fuller B, Killelea A, Strumpf A, Powers SD, Rogawski McQuade ET. Geographic Variation in Qualified Health Plan Coverage and Prior Authorization Requirements for HIV Preexposure Prophylaxis. JAMA Netw Open 2023; 6:e2342781. [PMID: 37948076 PMCID: PMC10638648 DOI: 10.1001/jamanetworkopen.2023.42781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 09/29/2023] [Indexed: 11/12/2023] Open
Abstract
Importance HIV preexposure prophylaxis (PrEP) is a key component of the Ending the HIV Epidemic (EHE) Initiative to curb new HIV diagnoses. In October 2019, emtricitabine/tenofovir alafenamide was added as an approved formulation for PrEP in addition to emtricitabine/tenofovir disoproxil fumarate; despite availability of another formulation with a similar prevention indication, variations in coverage may limit access. Objective To assess qualified health plan (QHP) coverage, prior authorization (PA) requirements, and specialty tiering for emtricitabine/tenofovir disoproxil fumarate and emtricitabine/tenofovir alafenamide following emtricitabine/tenofovir alafenamide approval as a PrEP treatment. Design, Setting, and Participants This cross-sectional study analyzed QHPs in the US that were compliant with the Patient Protection and Affordable Care Act from 2018 to 2020. QHPs were categorized by region and EHE priority jurisdictions. Data analysis occurred from March 2022 to March 2023. Exposures Enrollment in a qualified health plan certified by the Patient Protection and Affordable Care Act. Main Outcome and Measures Annual variation in QHP coverage and PA requirement for emtricitabine/tenofovir disoproxil fumarate and/or emtricitabine/tenofovir alafenamide. Descriptive statistics were reported for all outcomes. A secondary outcome was whether the PrEP formulation was determined by the QHP to be placed on a specialty drug tier. Results A total of 58 087 QHPs (19 533 for 2018; 17 007 for 2019; and 21 547 for 2020) were analyzed. QHPs covered emtricitabine/tenofovir disoproxil fumarate (19 165 QHPs [98.1%] in 2018; 16 970 QHPs [99.8%] in 2019; 20 045 QHPs [94.8%] in 2020) at a higher rate than emtricitabine/tenofovir alafenamide (17 391 QHPs [91.9%] in 2018; 15 757 QHPs [92.7%] in 2019; 18 836 QHPs [87.4%] in 2020). QHPs in the South required exclusive PA (ie, PA for 1 of the formulations even if the QHP covered both) for emtricitabine/tenofovir disoproxil fumarate and emtricitabine/tenofovir alafenamide at the highest rates in all 3 years. In the South, the rate of PA for emtricitabine/tenofovir disoproxil fumarate increased from 806 of 8023 QHPs (10.0%) in 2018 to 3466 of 7401 QHPs (46.8%) in 2020. QHPs with exclusive PA requirement for emtricitabine/tenofovir disoproxil fumarate were higher in EHE jurisdictions than non-EHE jurisdictions (difference: 2018, 0.9 percentage points; 2019, 3.5 percentage points; 2020, 29.1 percentage points). QHPs were more likely to place emtricitabine/tenofovir disoproxil fumarate on a specialty tier compared with emtricitabine/tenofovir alafenamide (difference: 2018, 1.8 percentage points; 2019, 3.7 percentage points; 2020, 4.1 percentage points). Conclusions and Relevance In this cross-sectional study, despite similar indications for biomedical prevention, QHPs were more likely to cover emtricitabine/tenofovir disoproxil fumarate than emtricitabine/tenofovir alafenamide, and QHPs were also more likely to subject emtricitabine/tenofovir disoproxil fumarate to PA or place it on a specialty tier despite the broader clinical indication. QHP PA requirements of emtricitabine/tenofovir disoproxil fumarate following emtricitabine/tenofovir alafenamide approval does not reflect clinical guidelines. The requirements could reflect differences in clinical indication, manufacturer discounts, or anticipation of a changing regulations and emerging generics. High rates of exclusive PA for emtricitabine/tenofovir disoproxil fumarate in areas where rates of HIV diagnoses are highest and PrEP is most needed (eg, the South and EHE priority jurisdictions) is concerning; policy solutions to address the growing PrEP health equity crisis could include regulator actions and a national PrEP program.
Collapse
Affiliation(s)
- Kathleen A. McManus
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville
| | - Benjamin Fuller
- Department of Medicine, University of Virginia, Charlottesville
| | | | - Andrew Strumpf
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville
| | - Samuel D. Powers
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville
| | - Elizabeth T. Rogawski McQuade
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville
- Public Health Sciences, University of Virginia, Charlottesville
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| |
Collapse
|
19
|
Christine PJ, Larochelle MR, Lin L(A, McBride J, Tipirneni R. Removal of Medicaid Prior Authorization Requirements and Buprenorphine Treatment for Opioid Use Disorder. JAMA Health Forum 2023; 4:e233549. [PMID: 37862034 PMCID: PMC10589810 DOI: 10.1001/jamahealthforum.2023.3549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 08/17/2023] [Indexed: 10/21/2023] Open
Abstract
Importance Buprenorphine treatment for opioid use disorder (OUD) is associated with decreased morbidity and mortality. Despite its effectiveness, buprenorphine uptake has been limited relative to the burden of OUD. Prior authorization (PA) policies may present a barrier to treatment, though research is limited, particularly in Medicaid populations. Objective To assess whether removal of Medicaid PAs for buprenorphine to treat OUD is associated with changes in buprenorphine prescriptions for Medicaid enrollees. Design, Setting, and Participants This state-level, serial cross-sectional study used quarterly data from 2015 through the first quarter (January-March) of 2019 to compare buprenorphine prescriptions in states that did and did not remove Medicaid PAs. Analyses were conducted between June 10, 2021, and August 15, 2023. The study included 23 states with active Medicaid PAs for buprenorphine in 2015 that required similar PA policies in fee-for-service and managed care plans and had at least 2 quarters of pre- and postperiod buprenorphine prescribing data. Exposures Removal of Medicaid PA for at least 1 formulation of buprenorphine for OUD. Main Outcomes and Measures The main outcome was number of quarterly buprenorphine prescriptions per 1000 Medicaid enrollees. Results Between 2015 and the first quarter of 2019, 6 states in the sample removed Medicaid PAs for at least 1 formulation of buprenorphine and had at least 2 quarters of pre- and postpolicy change data. Seventeen states maintained buprenorphine PAs throughout the study period. At baseline, relative to states that repealed PAs, states that maintained PAs had lower buprenorphine prescribing per 1000 Medicaid enrollees (median, 6.6 [IQR, 2.6-13.9] vs 24.1 [IQR, 8.7-27.5] prescriptions) and lower Medicaid managed care penetration (median, 38.5% [IQR, 0.0%-74.1%] vs 79.5% [IQR, 78.1%-83.5%] of enrollees) but similar opioid overdose rates and X-waivered buprenorphine clinicians per 100 000 population. In fully adjusted difference-in-differences models, removal of Medicaid PAs for buprenorphine was not associated with buprenorphine prescribing (1.4% decrease; 95% CI, -31.2% to 41.4%). For states with below-median baseline buprenorphine prescribing, PA removal was associated with increased buprenorphine prescriptions per 1000 Medicaid enrollees (40.1%; 95% CI, 0.6% to 95.1%), while states with above-median prescribing showed no change (-20.7%; 95% CI, -41.0% to 6.6%). Conclusions and Relevance In this serial cross-sectional study of Medicaid PA policies for buprenorphine for OUD, removal of PAs was not associated with overall changes in buprenorphine prescribing among Medicaid enrollees. Given the ongoing burden of opioid overdoses, continued multipronged efforts are needed to remove barriers to buprenorphine care and increase availability of this lifesaving treatment.
Collapse
Affiliation(s)
- Paul J. Christine
- Section of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora
| | - Marc R. Larochelle
- Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, Massachusetts
- Section of General Internal Medicine, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | - Lewei (Allison) Lin
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Addiction Center, Department of Psychiatry, University of Michigan Medical School, Ann Arbor
| | - Jonathon McBride
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Renuka Tipirneni
- Division of General Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| |
Collapse
|
20
|
Choi DK, Cohen NA, Choden T, Cohen RD, Rubin DT. Delays in Therapy Associated With Current Prior Authorization Process for the Treatment of Inflammatory Bowel Disease. Inflamm Bowel Dis 2023; 29:1658-1661. [PMID: 36715294 DOI: 10.1093/ibd/izad012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Indexed: 01/31/2023]
Abstract
Lay Summary
Despite a high approval rate, there were unnecessary delays in therapy due to prior authorizations. This study identified the impact of type of IBD, FDA-labeled indication, and dose escalations on approvals.
Collapse
Affiliation(s)
- David K Choi
- From the University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Nathaniel A Cohen
- From the University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Tenzin Choden
- From the University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Russell D Cohen
- From the University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - David T Rubin
- From the University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| |
Collapse
|
21
|
Chino F, Baez A, Elkins IB, Aviki EM, Ghazal LV, Thom B. The Patient Experience of Prior Authorization for Cancer Care. JAMA Netw Open 2023; 6:e2338182. [PMID: 37851442 PMCID: PMC10585404 DOI: 10.1001/jamanetworkopen.2023.38182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/04/2023] [Indexed: 10/19/2023] Open
Abstract
Importance Prior authorization (PA) requires clinicians and patients to navigate a complex approval pathway. Resultant delays and denials can be particularly problematic for patients with cancer, who often need urgent treatment or symptom management. Objective To investigate the patient perspective of PA for cancer-related care, including perceptions about the process, outcomes (including delays and denials), and patient administrative burden. Design, Setting, and Participants This cross-sectional, anonymous survey used a convenience sample of patients with PA experience. Participants were recruited using social media and email lists of US-based cancer advocacy organizations from July 1 to October 6, 2022. Exposure Prior authorization for any cancer-related service. Main Outcomes and Measures Delays to care, outcome of PA, communication, and changes in anxiety (measured on a scale of 0-100, with 0 indicating no anxiety and higher scores indicating higher levels of anxiety) and trust. Results Of 178 respondents (158 women [88%], 151 non-Hispanic White respondents [84%], 164 respondents [92%] <65 years), 112 (63%) reported that their cancer care was approved and given as recommended, and 39 (22%) did not receive recommended care due to delays or denials. Most respondents (123 [69%]) reported a PA-related delay in care; of those with delayed care, 90 (73%) reported a delay of 2 or more weeks. Most respondents (119 [67%]) had to personally become involved in the PA process; 35 (20%) spent 11 or more hours dealing with PA issues. Overall, the PA experience was rated as bad (70 [40%]) or horrible (55 of 174 [32%]); ratings were associated with the length of delay (ρ = 0.36; P < .001) and the time spent on PA (ρ = 0.42; P < .001). Self-reported PA-related anxiety was higher than usual anxiety (mean [SD] score, 74.7 [20.2] vs 37.5 [22.6]; P < .001) and was correlated with delay length (ρ = 0.16; P = .04), time spent on PA (ρ = 0.27; P < .001), and overall PA experience (ρ = 0.34; P < .001). After PA, 159 respondents (89%) trusted their insurance company less, and 148 respondents (83%) trusted the health care system less. Patient involvement in the PA process was associated with increased odds of distrusting their insurance company (β = 6.0; 95% CI, 1.9-19.2) and the health care system (β = 3.3; 95% CI, 1.4-8.1) and of having a negative experience (β = 6.6; 95% CI, 3.1-14.3). Conclusions and Relevance This survey-based cross-sectional study of the patient experience with PA highlights an adverse outcome of PA: 22% of patients did not receive the care recommended by their treatment team because of PA. Most respondents experienced a delay in recommended oncology care, and delays were associated with increased anxiety, a negative perception of the PA process, and patient administrative burden.
Collapse
Affiliation(s)
- Fumiko Chino
- Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | | | - Emeline M. Aviki
- Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Surgery, Gynecology Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Bridgette Thom
- Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| |
Collapse
|
22
|
Loeb L, Nasir A, Picco MF, Hashash JG, Kinnucan JA, Farraye FA. Prior Authorization of Biologics in the Management of Inflammatory Bowel Disease. Inflamm Bowel Dis 2023; 29:e37. [PMID: 37196096 DOI: 10.1093/ibd/izad088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Affiliation(s)
- Lauren Loeb
- Department of Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Ayan Nasir
- Department of Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Michael F Picco
- Inflammatory Bowel Disease Center, Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Jana G Hashash
- Inflammatory Bowel Disease Center, Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Jami A Kinnucan
- Inflammatory Bowel Disease Center, Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Francis A Farraye
- Inflammatory Bowel Disease Center, Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| |
Collapse
|
23
|
Powell AC, Lugo CT, Pickerell JT, Long JW, Loy BA, Mirhadi AJ. An assessment of the association between patient race and prior authorization program determinations in the context of radiation therapy. Healthc (Amst) 2023; 11:100704. [PMID: 37598613 DOI: 10.1016/j.hjdsi.2023.100704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 12/16/2022] [Accepted: 06/08/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND When a physician determines that a patient needs radiation therapy (RT), they submit an RT order to a prior authorization program which assesses guideline-concordance. A rule-based clinical decision support system (CDSS) evaluates whether the order is appropriate or potentially non-indicated. If potentially non-indicated, a board-certified oncologist discusses the order with the ordering physician. After discussion, the order is authorized, modified, withdrawn, or recommended for denial. Although patient race is not captured during ordering, bias prior to and during ordering, or during the discussion, may influence outcomes. This study evaluated if associations existed between race and order determinations by the CDSS and by the overall prior authorization program. METHODS RT orders placed in 2019, pertaining to patients with Medicare Advantage health plans from one national organization, were analyzed. The association between race and prior authorization outcomes was examined for RT orders for all cancers, and then separately for breast, lung, and prostate cancers. Analyses controlled for the patient's age, urbanicity, and the median income in the patient's ZIP code. Adjusted analyses were conducted on unmatched and racially-matched samples. RESULTS Of the 10,145 patients included in the sample, 8,061 (79.5%) were White and 2,084 (20.5%) were Black. Race was not found to have a significant association with CDSS or prior authorization outcomes in any of the analyses. CONCLUSIONS CDSS and prior authorization outcomes suggested similar rates of clinical appropriateness of orders for patients, regardless of race. IMPLICATIONS Prior authorization utilizing rule-based CDSS was capable of enforcing guidelines without introducing racial bias.
Collapse
Affiliation(s)
- Adam C Powell
- HealthHelp, 16945 Northchase Drive, Suite 1300, Houston, TX, 77060, USA; Payer+Provider Syndicate, 20 Oakland Ave., Newton, MA, 02466, USA.
| | | | | | - James W Long
- Humana, 500 W. Main St., Louisville, KY, 40202, USA
| | - Bryan A Loy
- Humana, 500 W. Main St., Louisville, KY, 40202, USA
| | - Amin J Mirhadi
- HealthHelp, 16945 Northchase Drive, Suite 1300, Houston, TX, 77060, USA
| |
Collapse
|
24
|
Warnock N. Prior Authorization: Process Redesign with a Focus on Value-Based Care. Popul Health Manag 2023; 26:S21-S22. [PMID: 37603808 DOI: 10.1089/pop.2023.0146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023] Open
Affiliation(s)
- Neil Warnock
- US Medical Affairs-Market Access-Data Generation Observational Studies, Bayer Pharmaceuticals, Whippany, New Jersey, USA
| |
Collapse
|
25
|
Agarwal A, Stoff B. Prior authorization exemption laws: Challenges and opportunities for dermatology. Clin Dermatol 2023; 41:538-539. [PMID: 37579892 DOI: 10.1016/j.clindermatol.2023.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2023]
Affiliation(s)
- Aneesh Agarwal
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Benjamin Stoff
- Department of Dermatology, Emory School of Medicine, Atlanta, Georgia, USA; Emory Center for Ethics, Atlanta, Georgia, USA
| |
Collapse
|
26
|
Kebaish KJ, Galivanche AR, Mercier MR, Varthi AG, Rubin LE, Grauer JN. Is There Utility to Requiring Spine MRI Pre-authorizations? Pre-authorizations: A Single Institution's Perspective. Clin Spine Surg 2023; 36:186-189. [PMID: 36728293 DOI: 10.1097/bsd.0000000000001422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 12/13/2022] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN A retrospective cohort study of a patient undergoing treatment at a single institution's Spine Center. OBJECTIVE The current study assessed the rates and eventual disposition of pre-authorizations required before spine MRIs are ordered from an academic spine center. SUMMARY OF BACKGROUND DATA Spine magnetic resonance imaging (MRI) often requires preauthorization by insurance carriers. While there are potential advantages to ensuring consistent indicators for imaging modalities, previous studies have found that such processes can add administrative burdens and barriers to care. METHODS Patients from a single academic institution's spine center who were covered by commercial insurance and had a spine MRI ordered between January 2013 and December 2019 were identified. The requirement for preauthorization and eventual disposition of each of these studies was tracked. Multivariate logistic regression was used to determine if commercial insurance carriers or anatomic region MRIs were associated with requiring a preauthorization. The eventual disposition of studies associated with this process was tracked. RESULTS In total, 2480 MRI requests were identified, of which preauthorization was needed for 2122 (85.56%). Relative to cervical spine scans, preauthorization had greater odds of being required for thoracic (OR=2.71, P =0.003) and lumbar (OR=2.46, P <0.001) scans. Relative to a reference insurer, 4 of the 5 commercial carriers had statistically significant increased odds of requiring preauthorization (OR=1.54-10.17 P <0.050 for each).Of the imaging studies requiring preauthorization, peer to peer review was required for 204 (9.61%), and 1,747 (82.33% of all requiring preauthorization) were approved. Of 375 (17.67%) initially cancelled or denied by the preauthorization process, 290 (77.33% of those initially cancelled or denied) were completed within 3 months. In total, only 85 were not eventually approved and completed. CONCLUSION Of 2480 distinct MRI orders, commercial insurers required preauthorization for 85.56%. Nonetheless, 96.57% of all scans went on to be completed within 3 months, raising questions about the costs, benefits, and overall value of this administrative process.
Collapse
Affiliation(s)
- Kareem J Kebaish
- Department of Orthopaedic Surgery, Keck Medical Center of the University of Southern California, Los Angeles, CA
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Anoop R Galivanche
- Department of Orthopaedic Surgery, University of California, San Francisco Medical Center, San Francisco, CA
| | - Michael R Mercier
- Division of Orthopaedics, Department of Surgery, University of Toronto, Toronto, ON M5T 1P5 CA
| | - Arya G Varthi
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Lee E Rubin
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Jonathan N Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| |
Collapse
|
27
|
Nguemeni Tiako MJ, Dolan A, Abrams M, Oyekanmi K, Meisel Z, Aronowitz SV. Thematic Analysis of State Medicaid Buprenorphine Prior Authorization Requirements. JAMA Netw Open 2023; 6:e2318487. [PMID: 37318805 PMCID: PMC10273019 DOI: 10.1001/jamanetworkopen.2023.18487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/30/2023] [Indexed: 06/16/2023] Open
Abstract
Importance Prior authorization (PA) requirements for buprenorphine are associated with lower provision of the medication for the treatment of opioid use disorder (OUD). While Medicare plans have eliminated PA requirements for buprenorphine, many Medicaid plans continue to require them. Objective To describe and classify buprenorphine coverage requirements based on thematic analysis of state Medicaid PA forms. Design, Setting, and Participants This qualitative study used a thematic analysis of 50 states' Medicaid PA forms for buprenorphine between November 2020 and March 2021. Forms were obtained from the jurisdiction's Medicaid websites and assessed for features suggesting barriers to buprenorphine access. A coding tool was developed based on a review of a sample of forms, including fields for behavioral health treatment recommendations or mandates, drug screening requirements, and dosage limitations. Main Outcomes and Measures Outcomes included PA requirements for different buprenorphine formulations. Additionally, PA forms were evaluated for various criteria such as behavioral health, drug screenings, dose-related recommendations or mandates or patient education. Results Among the total of 50 US states in the analysis, most states' Medicaid plans required PA for at least 1 formulation of buprenorphine. However, the majority did not require a PA for buprenorphine-naloxone. Four key themes of coverage requirements were identified: restrictive surveillance (eg, requirements for urine drug screenings, random drug screenings, pill counts), behavioral health treatment recommendations or mandates (eg, mandatory counseling or 12-step meeting attendance), interfering with or restricting medical decision-making (eg, maximum daily dosages of 16 mg, requiring additional steps for dosages higher than 16 mg), and patient education (eg, information about adverse effects and interactions with other medications). Eleven states (22%) required urine drug screenings, 6 states (12%) required random urine drug screenings, and 4 states (8%) required pill counts. Fourteen states' forms (28%) recommended therapy, and 7 (14%) required therapy, counseling, or participation in group sessions. Eighteen states (36%) specified dosage maximums; among them, 11 (22%) required additional steps for a daily dosage higher than 16 mg. Conclusion In this qualitative study of state Medicaid PA requirements for buprenorphine, themes were identified that included patient surveillance with drug screenings and pill counts, behavioral health treatment recommendations or mandates, patient education, and dosing guidance. These results suggest that state Medicaid plans' buprenorphine PA requirements for OUD are in conflict with existing evidence and may negatively affect states' efforts to address the opioid overdose crisis.
Collapse
Affiliation(s)
- Max Jordan Nguemeni Tiako
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Center for Emergency Care and Policy Research, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Urban Health Lab, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Abby Dolan
- Center for Emergency Care and Policy Research, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Urban Health Lab, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Matthew Abrams
- Center for Emergency Care and Policy Research, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- University of Central Florida, Orlando
| | - Kehinde Oyekanmi
- Center for Emergency Care and Policy Research, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Urban Health Lab, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Zachary Meisel
- Center for Emergency Care and Policy Research, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Shoshana V. Aronowitz
- Center for Emergency Care and Policy Research, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia
| |
Collapse
|
28
|
Luo J, Gellad WF. Electronic Prior Authorization for Prescription Drugs - Challenges and Opportunities for Reform. N Engl J Med 2023; 388:867-870. [PMID: 36876754 PMCID: PMC10880819 DOI: 10.1056/nejmp2214620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Affiliation(s)
- Jing Luo
- From the Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine (J.L., W.F.G.), and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (W.F.G.) - both in Pittsburgh
| | - Walid F Gellad
- From the Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine (J.L., W.F.G.), and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (W.F.G.) - both in Pittsburgh
| |
Collapse
|
29
|
Anderson KE, Alexander GC, Ma C, Dy SM, Sen AP. Medicare Advantage coverage restrictions for the costliest physician-administered drugs. Am J Manag Care 2022; 28:e255-e262. [PMID: 35852888 DOI: 10.37765/ajmc.2022.89184] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVES To examine the use of step therapy, prior authorization, and Part D formulary exclusion by 4 large Medicare Advantage (MA) insurers to manage 20 physician-administered drugs with the highest total Medicare expenditures (top 20 drugs). STUDY DESIGN We collected data for United Healthcare, CVS/Aetna, Humana, and Kaiser plans to create a database of 2020 Part B coverage restrictions and conducted a retrospective analysis of 2018-2020 Part D formularies. METHODS For each insurer, we calculated the number of top 20 physician-administered drugs subject to prior authorization and step therapy. For physician-administered drugs for which there were no similar or interchangeable alternatives, we examined which insurers required prior authorization or step therapy. Finally, we examined whether insurers restricted access to physician-administered drugs by reducing coverage on Part D formularies. RESULTS Of the top 20 physician-administered drugs, 17 were subject to prior authorization and 10 were subject to step therapy by at least 1 insurer. For 5 physician-administered drugs without a similar or interchangeable alternative, none were subject to step therapy and all were subject to prior authorization by at least 1 insurer. Across the 4 insurers, 16 physician-administered drugs were covered on all or some of the Part D formularies in 2018, which decreased to 6 in 2020. CONCLUSIONS Four large MA insurers managed access to expensive physician-administered drugs with a combination of prior authorization, step therapy, and Part D formulary design. When a low-cost alternative exists, these tools can help reduce wasteful spending, but the administrative barriers may also reduce access.
Collapse
Affiliation(s)
- Kelly E Anderson
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 E Montview Blvd, Mail Stop C238, Aurora, CO 80045.
| | | | | | | | | |
Collapse
|
30
|
Shah ED, Amann ST, Hobley J, Islam S, Taunk R, Wilson L. 2021 National Survey on Prior Authorization Burden and Its Impact on Gastroenterology Practice. Am J Gastroenterol 2022; 117:802-805. [PMID: 35296630 PMCID: PMC9060934 DOI: 10.14309/ajg.0000000000001728] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 03/08/2022] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Prior authorizations (PAs) are intended to control prescription drug expenditures. METHODS One hundred fifty-six physician and advanced practice provider members of the American College of Gastroenterology completed a national survey to assess PA burden and impact. RESULTS One-half of PA requests relate to prescription refills. Greater than 50% of the respondents choose inferior treatments at least weekly because of perceived PA burden for preferred agents. One-half of the respondents reported a patient who experienced serious adverse events due to PA-related care delays. DISCUSSION PA is an administrative burden that exhausts practice resources and may have a negative impact on patient care.
Collapse
Affiliation(s)
- Eric D. Shah
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Health, Lebanon, New Hampshire, USA
| | | | - James Hobley
- GastroIntestinal Specialists, Shreveport, Louisiana, USA
| | | | - Raja Taunk
- Anne Arundel Gastroenterology Associates, Annapolis, Maryland, USA
| | - Louis Wilson
- Wichita Falls Gastroenterology Associates, Wichita Falls, Texas, USA
| |
Collapse
|
31
|
Panzer AD, Margaretos NM, Bridger N, Osani MC, Lai RC, Chambers JD. Patients' access to 2018 FDA-approved drugs 1 year post approval. Am J Manag Care 2022; 28:e153-e156. [PMID: 35420754 DOI: 10.37765/ajmc.2022.88869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVES To examine US commercial health plans' adoption of 2018 FDA-approved drugs. STUDY DESIGN Database analysis. METHODS We identified novel drugs that the FDA approved in 2018 and categorized them as follows: cancer treatment, orphan drug, included in an expedited review program, and biosimilar. Using a data set of 17 large health plans' drug coverage policies and formularies, we examined coverage 1 year following FDA approval. RESULTS The FDA approved 66 drugs in 2018 (5 were not yet marketed 1 year following approval). For 60 of 61 drugs, some plans issued coverage policies whereas other plans included the drug in their formularies. Plans imposed restrictions (eg, step therapy) in 37% (275/742) of coverage policies. Plans covered biosimilars, orphan drugs, and cancer treatments more generously than drugs not in those categories (P < .05). Plans imposed restrictions in their policies with different frequencies (range, 7%-52%). Plans imposed utilization management (UM) in 82% (3837/4697) of formulary entries. Of those entries, plans required prior authorizations in 98%, included drugs on the highest patient co-payment tier in 70%, and imposed step therapy in 3%. Plans most often placed orphan drugs and cancer treatments on the highest cost-sharing formulary tiers (68% and 64% of the time, respectively). Plans imposed UM in their formularies with different frequencies (range, 62%-100% of entries). CONCLUSIONS Health plans imposed fewer coverage restrictions on cancer treatments, orphan drugs, and biosimilars than on drugs not in those categories. Some plans covered 2018 FDA-approved drugs more generously than others, which has implications for patients' access to innovative therapies.
Collapse
Affiliation(s)
- Ari D Panzer
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington St #63, Boston, MA 02111.
| | | | | | | | | | | |
Collapse
|
32
|
Marble KY, Briggs GR, Gordy XZ. Improvements for the Prior Authorization Process for Elective Surgical Procedures at an Academic Medical Center. Perspect Health Inf Manag 2022; 19:1l. [PMID: 35440929 PMCID: PMC9013228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Prior authorization is an approval process to ensure that services provided by healthcare organizations will be reimbursed by insurance carriers. Prior authorization denials can result in revenue loss. Due to multiple prior authorization issues, over $21 million in charges was denied, and $291,217.63 was ultimately written off as uncollectible in a one-year period at the Department of Surgery at Hospital X. This paper aimed to design an improved process to reduce, or eliminate, the issues causing charges to be written off. Three divisions with the most prior authorization denials within the department were identified. A comprehensive review of the current prior authorization process was conducted. Each division was found to have a unique prior authorization issue that was causing charges to be written off. Barriers were identified, educational training was provided accordingly, and process changes were implemented thereafter. When comparing the results pre- and post-interventions, these interventions resulted in these charges no longer being denied or written off. The processes utilized here can be easily replicated for organizations with similar barriers.
Collapse
|
33
|
Vishwanath S, Tran SN, Pomfret TC, Boss KC, Tesell M, Price M, Alper CJ, Muchnik L, Clements KM, Lenz K. Evaluating proactive outreach for prior authorization recertifications in Medicaid patients. Am J Manag Care 2021; 27:e395-e399. [PMID: 34784148 DOI: 10.37765/ajmc.2021.88783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
OBJECTIVES To assess the effectiveness of a proactive provider intervention in prompting prior authorization (PA) submissions or provider response prior to PA expiration for medically complex Medicaid patients. STUDY DESIGN Pre-post outreach study with data from pharmacy claims and provider outreach. METHODS The intervention and historical comparison (control) groups included expired PAs from December 2019 to February 2020 and from December 2018 to February 2019, respectively. Provider outreach, including telephonic and fax attempts, was conducted over a 2-week period prior to PA expiration. Outcomes were classified as positive or negative based on provider conversation coupled with the result (eg, PA submission) for the intervention group and based solely on pharmacy claims for the control group. The primary end point was the percentage of positive outcomes between the groups, analyzed via χ2 test. The time from PA expiration to the new PA submission was evaluated via t test. RESULTS A total of 342 outreach attempts were conducted for 270 PAs representing 193 unique patients. Outreach was more likely to result in positive outcomes in the intervention group vs no outreach in the control group (87% vs 25%; P < .00001). On average, PAs were submitted 3.5 days prior to expiration in the intervention group vs 13.0 days after expiration in the control group (t = -7.50; P < .00001). CONCLUSIONS Proactive outreach resulted in a greater percentage of PA submissions and a significantly reduced time to PA submission. These findings provide important information for payers in guiding clinical programs to enhance continuity of care among at-risk populations.
Collapse
Affiliation(s)
| | - Stephanie N Tran
- UMass Chan Medical School-Commonwealth Medicine, 333 South St, Shrewsbury, MA 01545-7807.
| | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Choi DK, Patel S, Muran C, Khamo N, Patel R, Fayyaz N, West-Thielke P. Prior Authorization Burden on the Use of LCP-Tacrolimus in Abdominal Solid Organ Transplant Recipients. Ann Pharmacother 2021; 56:856-857. [PMID: 34612712 DOI: 10.1177/10600280211050641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
35
|
Hover AR. MSMA Helped Pass SB 514 Mitigating Onerous Requirements of Prior Authorization. Mo Med 2021; 118:310. [PMID: 34373656 PMCID: PMC8343647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Affiliation(s)
- Alexander R Hover
- President of the Missouri State Medical Association for 2021-2022. He is a Gastroenterologist from Ozark, Missouri
| |
Collapse
|
36
|
Eyal N, Gerhard T, Strom BL. Strengthening and accelerating SARS-CoV-2 vaccine safety surveillance through registered pre-approval rollout after challenge tests. Vaccine 2021; 39:3455-3458. [PMID: 34023137 PMCID: PMC8084609 DOI: 10.1016/j.vaccine.2021.04.056] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 04/26/2021] [Accepted: 04/27/2021] [Indexed: 12/20/2022]
Affiliation(s)
- Nir Eyal
- Center for Population-Level Bioethics and Department of Philosophy, Rutgers University, New Brunswick, NJ, USA, Department of Health Behavior, Society and Policy, Rutgers School of Public Health, Piscataway, NJ, USA; Rutgers Biomedical and Health Sciences, Newark, NJ, USA
| | - Tobias Gerhard
- Center for Pharmacoepidemiology and Treatment Science, Rutgers University, New Brunswick, NJ, USA, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ, USA; Rutgers Biomedical and Health Sciences, Newark, NJ, USA
| | - Brian L Strom
- Rutgers Biomedical and Health Sciences, Newark, NJ, USA.
| |
Collapse
|
37
|
Carico R, West R, Miller T, Brown J, Baum D, Dunaway S, Hill A, Finley W, Bates J, Fenerty J. Evaluation of a pharmacy technician-based medication prior authorization program. J Am Pharm Assoc (2003) 2021; 61:425-431. [PMID: 33771445 DOI: 10.1016/j.japh.2021.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 02/12/2021] [Accepted: 02/22/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND The roles of pharmacy technicians in clinical practice are being explored. Medication prior authorizations (PAs) from insurers can lead to delays in pharmacotherapy. OBJECTIVE To assess the efficiency of our clinical pharmacy technicians in processing PAs for medications. PRACTICE DESCRIPTION Outpatient clinics in a comprehensive health care provider group. PRACTICE INNOVATION PA requests are routed to technicians for initial data collection. Clinical pharmacists can review their work before submission. EVALUATION METHODS Clinical pharmacy staff in 4 clinics recorded information about PA requests from January 21, 2020, to April 21, 2020. In 3 of the clinics, PA requests were primarily processed by clinical pharmacy technicians. In another clinic, requests were processed by a clinical pharmacist. Information collected included the date the request was received, outcomes (e.g., approval, therapy change, or nonapproval), and the date of final outcome. Descriptive statistics were prepared, including number of requests that were approved, number of business days between request and decision, and final outcome. RESULTS Overall, 720 PA requests were received. Of these, 88.6% were approved with first response, and 673 (93.5%) were eventually approved. Median time to first response was 0 business days, regardless of clinic. In 75% of cases, first response was within 1 business day. PA characteristics varied across clinics; however, PA approval percentages were comparable (91.2%-94.3%). CONCLUSION In an assessment of clinical pharmacy technicians' efficiency in responding to pharmacy plan PA requests, more than 90% were approved, often within one business day. Our results must be interpreted in light of local factors and a virus pandemic during the study. However, results of requests handled by technicians were similar to results when the requests were handled by a clinical pharmacist. Clinical pharmacy technicians can be efficient and cost-effective in this role.
Collapse
|
38
|
Mark TL, Parish WJ, Weber EM, Zarkin GA. Prior Authorization for Opioid Use Disorder Versus Pain Medications: Lessons Learned for Parity Enforcement. J Stud Alcohol Drugs 2021; 82:214-218. [PMID: 33823968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023] Open
Abstract
OBJECTIVE This study characterized the use of prior authorization for opioid use disorder medications as compared with that for opioid pain medications in the United States among Medicare Part D plans. METHOD Medicare Part D formulary data from 2017-2019 were used to describe differences in prior authorization between opioid use disorder medications and opioid pain medications. RESULTS In 2017, 72% of Medicare Part D formularies required prior authorization for brand buprenorphine-naloxone, whereas 6% of formularies required prior authorization for brand oxycodone. In 2019, 3% of formularies required prior authorization for brand buprenorphine-naloxone, whereas 16% of formularies required prior authorization for brand oxycodone. Throughout the study period, other formulary restrictions such as quantity limits were similar for both medications. CONCLUSIONS The disparate use of prior authorization in 2017 for opioid use disorder medications as compared with opioid pain medications suggests that formulary decision making may be inconsistent between medications used to treat substance use disorders and those used to treat pain. If Part D formularies publicly released their decision-making criteria, then there would be a greater understanding of why prior authorization was differentially applied. Greater transparency would help ensure that formulary decisions are not the result of biases and stigma toward substance use disorders.
Collapse
Affiliation(s)
| | | | | | - Gary A Zarkin
- RTI International, Research Triangle Park, North Carolina
| |
Collapse
|
39
|
Hecht B, Frye C, Holland W, Holland CR, Rhodes LA, Marciniak MW. Analysis of prior authorization success and timeliness at a community-based specialty care pharmacy. J Am Pharm Assoc (2003) 2021; 61:S173-S177. [PMID: 33618986 DOI: 10.1016/j.japh.2021.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 12/18/2020] [Accepted: 01/03/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Specialty medications may require a prior authorization (PA) before a patient can access the medication. Providers often identify PA approval as a burden for the practice. Pharmacists can facilitate the completion of the PA process. OBJECTIVE The primary objective was to evaluate the time to first PA decision (approval or denial) for dermatologic medications dispensed by a community-based specialty pharmacy. A secondary objective was to compare PA timeliness (time to PA approval and time to first medication fill) between a community-based specialty pharmacy and a dermatology provider office. PRACTICE DESCRIPTION Realo Specialty Care is a community-based independent specialty pharmacy that provides comprehensive care to patients with complex and chronic conditions such as plaque psoriasis, hidradenitis suppurativa, and atopic dermatitis. Pharmacy services include PA assistance, comprehensive medication management, patient education, and adherence monitoring. PRACTICE INNOVATION Pharmacy dispensing system data were used to conduct a retrospective analysis of the effectiveness at resolving PA requests. PAs are traditionally completed by a provider's practice, and data are documented within the pharmacy system as a PA task. EVALUATION METHODS Data included PA tasks for dermatology prescriptions for patients aged 18 years or older between January 1, 2017, and June 30, 2019. Initial receipt of the prescription, PA decision, and PA decision date were noted in the PA task and confirmed via fax documentation. The date of first fill was confirmed by prescription data. RESULTS The pharmacy completed 677 PA tasks with a mean time to PA decision of 1.9 days, whereas the provider's office averaged 20.9 days (P < 0.001). The pharmacy demonstrated a mean time to first fill of 6.6 days, whereas the provider's office averaged 16.2 days (P < 0.001). CONCLUSION Pharmacies can effectively complete PAs to expedite the filling process for patients and increase medication access. Provider practices could benefit from delegating these tasks to a partnered pharmacy.
Collapse
|
40
|
Petitt CE, Kiracofe E, Adamson A, Barbieri JS. Prior authorizations in dermatology and impact on patient care: An updated survey of US dermatology providers and staff by the American Academy of Dermatology. Dermatol Online J 2021; 27:13030/qt990631n9. [PMID: 33560787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 02/02/2021] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Completing prior authorizations (PAs) can be a lengthy process, which can delay access to appropriate care. A 2017 American Academy of Dermatology survey highlighted that PAs are common across many dermatologic medication classes. However, little is known regarding the impact of PAs on patient care and resource use. METHODS To better characterize the burden of PAs on dermatology practices and their effects on patient care, a survey was conducted in February 2020 among U.S.-based dermatologists (N=3,000) and the Association of Dermatology Administrators/Managers (ADAM) members (N=718). RESULTS Respondents reported 24% of patients require PAs. Dermatologists and staff spend a mean of 3.3 hours/day on PAs. Sixty percent of dermatologists reported interrupting patient visits for PAs. Sixty-five percent respondents reported PAs were required for clobetasol, 76% for tretinoin, and 42% for 5-fluorouracil. Respondents noted 45% of PA determinations took beyond one week and 17% took beyond two weeks. Respondents reported 12% of PAs resulted in delaying or abandoning treatment and 17% resulted in less appropriate treatment. CONCLUSIONS Prior authorization burden remains high and consumes substantial clinical resources, which may negatively impact patient care. Additionally, they result in prolonged treatment delays and are associated with delaying treatment, abandoning treatment, or using lesser treatment.
Collapse
Affiliation(s)
| | | | | | - John S Barbieri
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
| |
Collapse
|
41
|
Hruza GJ. Unintended Consequences of Prior Authorization. Mo Med 2020; 117:505-506. [PMID: 33311765 PMCID: PMC7721422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- George J Hruza
- MSMA member since 1989, is the 2020-2021 President. He practices Dermatology in St. Louis, Missouri
| |
Collapse
|
42
|
Moore SL, Portz JD, Santodomingo M, Elsbernd K, McHale M, Massone J. Using Telehealth for Hospice Reauthorization Visits: Results of a Quality Improvement Analysis. J Pain Symptom Manage 2020; 60:e22-e27. [PMID: 32525082 PMCID: PMC7276118 DOI: 10.1016/j.jpainsymman.2020.06.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/01/2020] [Accepted: 06/01/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Increasing hospice need, a growing shortage of hospice providers, and concerns about in-person services because of coronavirus disease 2019 (COVID-19) require hospices to innovate care delivery. MEASURES This project compared outcomes between hospice reauthorization visits conducted via telehealth and in person. After each visit, providers, patients, and caregivers completed telehealth acceptance surveys, and providers recorded reauthorization recommendations. INTERVENTION Providers conducted 88 concurrent in-person and telehealth visits between June and November 2019. OUTCOMES No statistically significant differences in reauthorization recommendations were found between telehealth and in-person visits. Satisfaction with telehealth was high; 88% of patients/caregivers and 78% of providers found telehealth services as effective as in-person visits. CONCLUSIONS/LESSONS LEARNED Results indicate that telehealth can successfully support clinical decision making for hospice reauthorization. These findings show telehealth to be reliable and acceptable for certain types of hospice care even before COVID-19, which emphasizes its importance both during and after the current public health emergency.
Collapse
Affiliation(s)
- Susan L Moore
- Colorado School of Public Health, Aurora, Colorado, USA; University of Colorado School of Medicine, Aurora, Colorado, USA.
| | - Jennifer D Portz
- University of Colorado School of Medicine, Aurora, Colorado, USA
| | | | - Kira Elsbernd
- Division of Infectious Diseases and Tropical Medicine, University Hospital, Ludwig Maximilians Universität Munich, Munich, Germany; Institute for Medical Information Processing, Biometry, and Epidemiology, IBE, Ludwig Maximilians Universität Munich, Munich, Germany
| | | | | |
Collapse
|
43
|
Abstract
OBJECTIVES It is unclear on what basis Medicare drug plans impose coverage restrictions on orphan drugs. This study aims to investigate the factors associated with utilization controls in Medicare fee-for-service Part D formularies. STUDY DESIGN Cross-sectional analysis. METHODS We used multivariate logistic regression to assess the association between orphan drug characteristics and use of formulary utilization controls in 2016. We controlled for number of beneficiaries per drug, exclusivity expiration, and the number of plans and beneficiaries per formulary. We conducted sensitivity analyses using fixed and random effects. RESULTS On average, 85% of orphan drugs on a formulary were placed on its highest cost-sharing tier and 76% were subject to prior authorization (PA). Orphan drugs with annual costs of $50,000 or more had twice the odds of having PA requirements compared with less expensive ones. Relative to orphan drugs with a single indication, drugs with multiple indications were more likely to have restrictions. Less effective drugs had 1.5 times the odds of highest tier placement relative to more effective drugs. The presence of black box warnings and patient assistance programs were associated with more restricted access. Orphan drugs with generics were less likely to undergo restrictions than those without generics (all P < .05). CONCLUSIONS Plans are making evidence-based decisions by rewarding more clinically effective and safer orphan drugs. They are penalizing drugs with multiple indications. Surprisingly, plans place fewer restrictions on orphan drugs that have a generic equivalent, which may further discourage generic entry into the orphan space, where competition is already sparse.
Collapse
Affiliation(s)
- Farah Yehia
- Department of Health Policy and Management, The Johns Hopkins University Bloomberg School of Public Health, Hampton House 496, 624 N Broadway St, Baltimore, MD 21205.
| | | | | |
Collapse
|
44
|
Webb J, Shah L, Lynch HF. No Easy Answers in Allocating Unapproved COVID-19 Drugs Outside Clinical Trials. Am J Bioeth 2020; 20:W1-W4. [PMID: 32840448 DOI: 10.1080/15265161.2020.1805525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
|
45
|
McManus KA, Powers S, Killelea A, Tello-Trillo S, Rogawski McQuade E. Regional Disparities in Qualified Health Plans' Prior Authorization Requirements for HIV Pre-exposure Prophylaxis in the United States. JAMA Netw Open 2020; 3:e207445. [PMID: 32492164 PMCID: PMC7272119 DOI: 10.1001/jamanetworkopen.2020.7445] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
IMPORTANCE With the goal of ending the HIV epidemic in the United States, access to HIV pre-exposure prophylaxis (PrEP) is essential to help curb new HIV infections. There has been differential uptake of PrEP by region, with the South lagging behind other regions. Discriminatory benefit design (benefit design that prevents or delays people with complex or expensive conditions from obtaining appropriate treatment) through prior authorization requirements could be a systemic barrier that contributes to the decreased PrEP uptake in the South. OBJECTIVES To investigate whether there are regional disparities in prior authorization requirements for combined tenofovir disoproxil fumarate and emtricitabine for qualified health plans (QHPs) and to assess whether any QHP characteristics explain the disparities. DESIGN, SETTING, AND PARTICIPANTS This design was a cross-sectional study of QHPs offered in the 2019 Affordable Care Act Marketplace. The QHPs studied included all Affordable Care Act-compliant individual and small-group market plans in the United States. EXPOSURES The primary exposure was the 4 census regions (Northeast, West, Midwest, and South). Additional covariates included other plan characteristics. MAIN OUTCOMES AND MEASURES Prior authorization requirement for combined tenofovir disoproxil fumarate and emtricitabine at the QHP level. RESULTS In total, 16 853 QHPs were analyzed (18.2% in the Northeast, 19.5% in the West, 25.0% in the Midwest, and 37.3% in the South). Overall, 18.9% of QHPs required prior authorization for combined tenofovir disoproxil fumarate and emtricitabine. This percentage varied by region, with 2.3%, 6.2%, 13.3%, and 37.3% of plans requiring prior authorization in the Northeast, West, Midwest, and South, respectively. Compared with QHPs in the Northeast, QHPs in the South were 15.89 (95% CI, 12.57-20.09) times as likely to require prior authorization, whereas the Midwest and West were 5.69 (95% CI, 4.45-7.27) and 2.65 (95% CI, 2.02-3.47) times as likely, respectively. Other plan characteristics did not account for the regional variation. CONCLUSIONS AND RELEVANCE Compared with QHPs in the Northeast, QHPs in the South were almost 16 times as likely to require prior authorization for PrEP, and the reasons for these disparities are unknown. The prior authorization requirement is a possible barrier to PrEP access in the South, which is the region of the United States with the most annual new HIV diagnoses. There is limited regulation of QHPs' prior authorization requirements. Federal- or state-level health policy laws may be necessary to remove this system-level barrier to ending the HIV epidemic in the United States.
Collapse
Affiliation(s)
- Kathleen A. McManus
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville
- Center for Health Policy, University of Virginia, Charlottesville
| | - Samuel Powers
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville
| | - Amy Killelea
- Health Systems and Policy, NASTAD, Washington, DC
| | - Sebastian Tello-Trillo
- Center for Health Policy, University of Virginia, Charlottesville
- Batten School of Leadership and Public Policy, University of Virginia, Charlottesville
| | - Elizabeth Rogawski McQuade
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville
- Department of Public Health Sciences, University of Virginia, Charlottesville
| |
Collapse
|
46
|
Rao T, Kiptanui Z, Dowell P, Triebwasser C, Alexander GC, Harris I. Association of Formulary Exclusions and Restrictions for Opioid Alternatives With Opioid Prescribing Among Medicare Beneficiaries. JAMA Netw Open 2020; 3:e200274. [PMID: 32119095 PMCID: PMC7052746 DOI: 10.1001/jamanetworkopen.2020.0274] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Although there are many pharmacologic alternatives to opioids, it is unclear whether the structure of Medicare Part D formularies discourages use of the alternatives. OBJECTIVES To quantify the coverage of opioid alternatives and prevalence of prior authorization, step therapy, quantity limits, and tier placement for these drugs, and test whether these formulary exclusions and restrictions are associated with increased opioid prescribing to older adults at the county level. DESIGN, SETTING, AND PARTICIPANTS County fixed-effect models were estimated using a panel of counties across the 50 US states and the District of Columbia over calendar years 2015 and 2016. Data analysis was conducted from July 1 to September 23, 2019. The sample included 2721 counties in 2015 and 2671 counties in 2016 with sufficient data on Medicare Part D formulary design and opioid prescribing. MAIN OUTCOMES AND MEASURES County-level opioid prescribing rate (number of opioid claims divided by the number of overall claims) and counts of excluded opioid alternatives and opioid alternatives with prior authorization, step therapy, quantity limits, and high-tier placements. RESULTS A total of 30 nonopioid analgesics were examined across 28 997 Medicare plans in 2015 and 30 390 plans in 2016. Medicare plans did not cover a mean of 7% of these drugs (interquartile range, 10%; lower to upper limit, 0%-23%). Among covered nonopioids, prior authorization and step therapy were uncommon, with fewer than 5% affected by prior authorization and 0% by step therapy. However, 13% of covered nonopioids had quantity limits (interquartile range, 10%; lower to upper limit, 0%-31%) and 22% were in high-cost tiers (interquartile range, 38%; lower to upper limit, 0%-50%). Increases in the number of nonopioids excluded on Medicare plans in a county were associated with increased opioid prescribing (effect size relative to mean, 2.2%-3.7%; P = .004). Conversely, increases in the number of opioids not covered on Medicare plans in a county was found to be associated with decreased opioid prescribing (effect size relative to mean, 0.8%-1.5%; P = .02). None of the utilization management strategies (prior authorization, step therapy, and quantity limits) examined or high-cost tier placements of nonopioids were associated with increased opioid prescribing. CONCLUSIONS AND RELEVANCE Lack of Medicare coverage for pharmacologic alternatives to opioids may be associated with increased opioid prescribing.
Collapse
Affiliation(s)
- Tanvi Rao
- IMPAQ International LLC, Washington, District of Columbia
| | | | | | | | - G. Caleb Alexander
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | |
Collapse
|
47
|
Affiliation(s)
- Rami Doukky
- Division of Cardiology, Cook County Health, 1901 W. Harrison St., Chicago, IL, 60612, USA.
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA.
| |
Collapse
|
48
|
Folkers KM, Leone S, Caplan A. Patient advocacy organizations' information for patients on pre-approval access to investigational treatments. BMC Res Notes 2019; 12:706. [PMID: 31661023 PMCID: PMC6819417 DOI: 10.1186/s13104-019-4745-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 10/17/2019] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE To evaluate the availability of information regarding patient access to investigational treatments through clinical trials and non-trial pre-approval access pathways from a sample of patient advocacy organization (PAO) websites in the United States. RESULTS We systematically analyzed the content of 118 randomly selected PAO websites to assess whether they contained information on clinical trials and non-trial pathways-e.g., the U.S. Food and Drug Administration (FDA) expanded access (EA) program and right to try-over the course of two months from February to March 2019. A majority (81%, n = 96) of PAOs provided a link to ClinicalTrials.gov, and 73% (n = 86) had their own clinical trial finder or list of relevant trials. 23% (n = 27) mentioned EA, with 8% (n = 9) providing specific resources for FDA's EA program. 8% (n = 10) provided a statement on the passage of the federal right to try law. A majority of PAO websites contained information on clinical trials, but a minority discussed non-trial pre-approval access. The lack of information on the latter highlights an area in need of improvement.
Collapse
Affiliation(s)
- Kelly McBride Folkers
- Division of Medical Ethics, Department of Population Health, NYU School of Medicine, Translational Research Building, 227 E. 30th Street #754B, New York, NY 10016 USA
| | - Sarah Leone
- Division of Medical Ethics, Department of Population Health, NYU School of Medicine, Translational Research Building, 227 E. 30th Street #754B, New York, NY 10016 USA
| | - Arthur Caplan
- Division of Medical Ethics, Department of Population Health, NYU School of Medicine, Translational Research Building, 227 E. 30th Street #754B, New York, NY 10016 USA
| |
Collapse
|
49
|
Berlin J. System Failure: Houston Practices Fight WellCare for Payment. Tex Med 2019; 115:28-29. [PMID: 31613383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Several Houston-area practices say a botched technology conversion by insurer WellCare after it acquired a Medicare Advantage plan led to prior authorization and network confusion, undue denials, and unpaid claims by the barrelful.
Collapse
|
50
|
Parish LC, Parish JL, Lambert WC, Ciferni C. The Practice of Dermatology Ain't What It Used To Be: The Preauthorization Catastrophe. Skinmed 2019; 17:152-153. [PMID: 31496468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Lawrence Charles Parish
- Department of Dermatology and Cutaneous Biology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA;
- Parish Dermatology, Philadelphia, PA
| | - Jennifer L Parish
- Department of Dermatology and Cutaneous Biology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
- Parish Dermatology, Philadelphia, PA
| | - W Clark Lambert
- Department of Dermatology, Rutgers - New Jersey Medical School, Newark, NJ
- Department of Pathology and Laboratory Medicine, Rutgers - New Jersey Medical School, Newark, NJ
| | | |
Collapse
|