Providers
Life Sciences

The cost of "Wayward" prior authorizations

The SamaCare Team

The SamaCare Team

Photo by Josh Sorenson on Unsplash

Most providers agree that the prior authorization process is onerous. In fact, in a survey of 1,000 physicians across primary care and various specialties by the American Medical Association (AMA), 84% of physicians surveyed described the burden associated with prior authorizations as “high” or “extremely high.” 

However, this overall stat can obscure the challenges healthcare providers face with prior authorizations for physician-administered drugs. Prior authorizations tend to bifurcate into two categories: easy requests and wayward prior auths. In a sample from across SamaCare’s prior authorization data from April 1, 2020 - May 1, 2020, the majority of prior authorizations (~60%) were easily and quickly resolved within one day. But if most authorizations get resolved within a day, are we all just making a big fuss about nothing?

No — which becomes clear when you look at the ~40% of prior authorizations that are not immediately resolved. That remaining set took an average of 9.5 days to resolve as approved or denied, with 69% of those prior authorizations not approved prior to the intended date of service. Basically, if a practice and patient doesn’t get a prior authorization back in a day, they have to steel themselves for fighting with payers, delayed patient care by up to two business weeks, or the financial risk of using a drug without pre-approval. It’s when you look at those troublesome requests that it becomes obvious why everyone hates prior authorizations

This data aligns with physicians’ self-reported experiences with prior authorizations. In the same survey by the AMA, 91% reported that prior authorizations sometimes, often, or always delays patient access to necessary care. As a corollary, 91% of physicians who responded to this survey also indicated that prior authorizations have a significant or somewhat negative impact on patient care. 

The impact of prior authorizations on patient care goes beyond whether the request is approved; it also matters when that approval occurs relative to the intended start of treatment. Providers who use the SamaCare platform for prior authorization management frequently utilize “Approval Percentage Prior to Date of Service” as a crucial metric to understand the impact on patient care. This metric looks at whether the payer approved the prior authorization request, and if so, whether the approval arrived before the intended date of service for the patient to start the therapy. 75% of physicians surveyed by the AMA indicated that prior authorizations lead patients to abandon treatment, and 28% indicated that the prior authorization process has led to a “serious adverse event” for a patient in their care. Qualitatively, we frequently hear physicians across SamaCare’s network of provider partners describe the mental impact delays to treatment can have on patients, creating unnecessary stress and anxiety. 

In addition to delaying treatment and negatively impacting patient care, prior authorizations impose a high cost on healthcare providers. The AMA found that physicians and their staff spend an average of nearly two business days per week completing prior authorizations. This drain on resources not only impacts providers’ operating margins but also leads to decreased employee satisfaction and increased stress on staff, which can increase the likeliness of human errors. The result? Inferior patient care. 

This presents an enormous problem for pharmas who invest huge amounts of time and money to bring new drugs to market. Prior authorizations worsen the patient experience and reduce the likelihood that patients will get and stay on the optimal drug even after the prescription is written. To ensure that the right patients get the right drugs at the right time, pharmas must continuously invest in patient access. But what can pharmas do to address this “last mile” patient access problem of prior authorizations? We’ve seen that an accurate timely understanding of the patient journey, along with targeted investments in technology and people to unblock patient obstacles goes a long way. 

In another post, we’ll discuss some of the tactics used for the “wayward” requests that have led to a 50% reduction in time-to-approval and 2x improvement in percentage of approvals prior to the date of service. While these findings represent only the first step in understanding the opportunity to impact patient care by improving the prior authorization process, they provide encouraging evidence that providers and pharmaceutical companies can work together, with the help of technology, to improve patient access to physician-administered medication. 

Providers
Life Sciences

The cost of "Wayward" prior authorizations

The SamaCare Team

The SamaCare Team

Photo by Josh Sorenson on Unsplash

Most providers agree that the prior authorization process is onerous. In fact, in a survey of 1,000 physicians across primary care and various specialties by the American Medical Association (AMA), 84% of physicians surveyed described the burden associated with prior authorizations as “high” or “extremely high.” 

However, this overall stat can obscure the challenges healthcare providers face with prior authorizations for physician-administered drugs. Prior authorizations tend to bifurcate into two categories: easy requests and wayward prior auths. In a sample from across SamaCare’s prior authorization data from April 1, 2020 - May 1, 2020, the majority of prior authorizations (~60%) were easily and quickly resolved within one day. But if most authorizations get resolved within a day, are we all just making a big fuss about nothing?

No — which becomes clear when you look at the ~40% of prior authorizations that are not immediately resolved. That remaining set took an average of 9.5 days to resolve as approved or denied, with 69% of those prior authorizations not approved prior to the intended date of service. Basically, if a practice and patient doesn’t get a prior authorization back in a day, they have to steel themselves for fighting with payers, delayed patient care by up to two business weeks, or the financial risk of using a drug without pre-approval. It’s when you look at those troublesome requests that it becomes obvious why everyone hates prior authorizations

This data aligns with physicians’ self-reported experiences with prior authorizations. In the same survey by the AMA, 91% reported that prior authorizations sometimes, often, or always delays patient access to necessary care. As a corollary, 91% of physicians who responded to this survey also indicated that prior authorizations have a significant or somewhat negative impact on patient care. 

The impact of prior authorizations on patient care goes beyond whether the request is approved; it also matters when that approval occurs relative to the intended start of treatment. Providers who use the SamaCare platform for prior authorization management frequently utilize “Approval Percentage Prior to Date of Service” as a crucial metric to understand the impact on patient care. This metric looks at whether the payer approved the prior authorization request, and if so, whether the approval arrived before the intended date of service for the patient to start the therapy. 75% of physicians surveyed by the AMA indicated that prior authorizations lead patients to abandon treatment, and 28% indicated that the prior authorization process has led to a “serious adverse event” for a patient in their care. Qualitatively, we frequently hear physicians across SamaCare’s network of provider partners describe the mental impact delays to treatment can have on patients, creating unnecessary stress and anxiety. 

In addition to delaying treatment and negatively impacting patient care, prior authorizations impose a high cost on healthcare providers. The AMA found that physicians and their staff spend an average of nearly two business days per week completing prior authorizations. This drain on resources not only impacts providers’ operating margins but also leads to decreased employee satisfaction and increased stress on staff, which can increase the likeliness of human errors. The result? Inferior patient care. 

This presents an enormous problem for pharmas who invest huge amounts of time and money to bring new drugs to market. Prior authorizations worsen the patient experience and reduce the likelihood that patients will get and stay on the optimal drug even after the prescription is written. To ensure that the right patients get the right drugs at the right time, pharmas must continuously invest in patient access. But what can pharmas do to address this “last mile” patient access problem of prior authorizations? We’ve seen that an accurate timely understanding of the patient journey, along with targeted investments in technology and people to unblock patient obstacles goes a long way. 

In another post, we’ll discuss some of the tactics used for the “wayward” requests that have led to a 50% reduction in time-to-approval and 2x improvement in percentage of approvals prior to the date of service. While these findings represent only the first step in understanding the opportunity to impact patient care by improving the prior authorization process, they provide encouraging evidence that providers and pharmaceutical companies can work together, with the help of technology, to improve patient access to physician-administered medication.