Life Sciences

The prior authorization “monkey-in-the-middle” dilemma

The SamaCare Team

The SamaCare Team

Photo by wild wings on Unsplash

The growing obstacle prior authorizations pose to patient access to physician-administered medication is clear: according to a survey by the AMA, 88% of physicians believe the prior auth burden has increased over the past 5 years. This challenge begins before the provider has even started the prior authorization process: in another AMA study, 69% of physicians reported that it is difficult to determine whether a prescription or medical service requires prior authorization. This statistic aligns with the fact that only 20% of physicians surveyed by the National Council for Prescription Drug Programs (NCPDP) indicated they could access information on prior auth requirements digitally. The prior authorization process is so onerous that ⅓ of practices surveyed by the AMA reported hiring employees solely to handle prior authorizations. 

The impact of prior authorization hurdles on the commercial success of specialty drugs is also clear. Bain & Company research shows that doctors who positively rate their experience of working with a drug — distinct from the “product-related attributes such as clinical data” —, are ~2.5x more likely to prescribe it in the future. And, for 40% of prescribers surveyed by CoverMyMeds, prior authorization is the main pain point when prescribing specialty medications.

With significant motivation to address this barrier to patient access to treatment, what are pharmaceutical market access teams doing to help providers navigate the murky waters of the prior authorization process? For over two decades, pharmaceutical manufacturers have employed hub services teams to effectively build bridges to enable patient access. Through phone-based manual support for benefit investigations, drug delivery and administration support, copay assistance programs, patient advocacy, and more, hub services have driven better patient access to life-changing medicines. 

However, when it comes to supporting providers through the prior authorization process, hub services organizations, despite their best efforts, face what we call “the monkey in the middle” problem. In order to understand this problem, consider the flow of patient-sourced data and other prior authorization requirements from provider to payer and back. Unlike for traditional drugs, physician-administered drug prior authorizations lack a standardized industry protocol for passing information between providers and payers. The result is a unique process for any of the payers and drugs a practice might work with, with hundreds of forms and dozens of portals to manage.  In addition to the fragmented flow of data to submit to the payer, providers face an equally fragmented process of tracking the status of a request for prior authorization once it has been submitted. Providers still spend hours on the phone, managing reams of faxes, and convoluted payers portals to ascertain what has happened to prior authorization requests after they are submitted. 

Enter a hub services organization. With no means of understanding holistically the prior authorizations being submitted by a practice, and no authority to ascertain the status of any individual prior authorization with a payer, hub services teams are stranded without the ability to help providers. Rather than saving time by delivering answers, hubs must ask already overtaxed medical staff to spend additional time getting the hub services team up to speed. 

“The drug company patient and provider service teams mean well, but they don’t understand the payers like we do, and they can’t always get timely and accurate information from the payers the same way we can, which ends up making those services much less helpful.” says Erin Bishop, the Billing Manager at Associated Retinal Consultants.

This “monkey-in-the-middle” problem boils down to two factors that pharma market access teams currently lack: instant visibility into the obstacles practices and patients face in accessing physician-administered drugs, and leverage to help them address those issues before they spiral. A unified platform for prior authorization submission and tracking, like SamaCare, not only helps lessen the burden of prior authorization process inefficiencies on providers, but also empowers pharma market access teams with more holistic and immediate visibility into the status of prior authorizations submitted for their drugs. With better information and a more embedded position within existing prior authorization workflows, pharma market access teams would have more leverage to improve the process for providers. 

What actions could pharma access and reimbursement teams take if they were more entrenched in the prior authorization workflow? To begin, pharma access teams could help provide practices with forewarning if anything is missing from submission documentation based on a more universal understanding of payer requirements and common errors that lead to delayed or denied prior authorizations. With better data on the average time to approval across different payers for their drugs, pharmaceutical access and reimbursement teams could proactively follow up on prior authorizations that are delayed. With real-time access to prior authorization approval status, access and reimbursement teams could also more expediently help providers address and respond to denials. 

Providers and pharmaceutical market access teams share a common goal: to enable patient access to treatment. Pharma’s traditional approach — phone-based manual support — has made incredible progress to protect patient access, and will continue to play a key role going forward. However, prescribing complexity and prior authorization burdens, especially for physician-administered drugs, continue to increase. By adopting technologies that improve their visibility into access challenges and leverage to solve them, pharmas will be able to achieve a better HCP experience while ensuring the right patients get the right drugs at the right time.


Life Sciences

The prior authorization “monkey-in-the-middle” dilemma

The SamaCare Team

The SamaCare Team

Photo by wild wings on Unsplash

The growing obstacle prior authorizations pose to patient access to physician-administered medication is clear: according to a survey by the AMA, 88% of physicians believe the prior auth burden has increased over the past 5 years. This challenge begins before the provider has even started the prior authorization process: in another AMA study, 69% of physicians reported that it is difficult to determine whether a prescription or medical service requires prior authorization. This statistic aligns with the fact that only 20% of physicians surveyed by the National Council for Prescription Drug Programs (NCPDP) indicated they could access information on prior auth requirements digitally. The prior authorization process is so onerous that ⅓ of practices surveyed by the AMA reported hiring employees solely to handle prior authorizations. 

The impact of prior authorization hurdles on the commercial success of specialty drugs is also clear. Bain & Company research shows that doctors who positively rate their experience of working with a drug — distinct from the “product-related attributes such as clinical data” —, are ~2.5x more likely to prescribe it in the future. And, for 40% of prescribers surveyed by CoverMyMeds, prior authorization is the main pain point when prescribing specialty medications.

With significant motivation to address this barrier to patient access to treatment, what are pharmaceutical market access teams doing to help providers navigate the murky waters of the prior authorization process? For over two decades, pharmaceutical manufacturers have employed hub services teams to effectively build bridges to enable patient access. Through phone-based manual support for benefit investigations, drug delivery and administration support, copay assistance programs, patient advocacy, and more, hub services have driven better patient access to life-changing medicines. 

However, when it comes to supporting providers through the prior authorization process, hub services organizations, despite their best efforts, face what we call “the monkey in the middle” problem. In order to understand this problem, consider the flow of patient-sourced data and other prior authorization requirements from provider to payer and back. Unlike for traditional drugs, physician-administered drug prior authorizations lack a standardized industry protocol for passing information between providers and payers. The result is a unique process for any of the payers and drugs a practice might work with, with hundreds of forms and dozens of portals to manage.  In addition to the fragmented flow of data to submit to the payer, providers face an equally fragmented process of tracking the status of a request for prior authorization once it has been submitted. Providers still spend hours on the phone, managing reams of faxes, and convoluted payers portals to ascertain what has happened to prior authorization requests after they are submitted. 

Enter a hub services organization. With no means of understanding holistically the prior authorizations being submitted by a practice, and no authority to ascertain the status of any individual prior authorization with a payer, hub services teams are stranded without the ability to help providers. Rather than saving time by delivering answers, hubs must ask already overtaxed medical staff to spend additional time getting the hub services team up to speed. 

“The drug company patient and provider service teams mean well, but they don’t understand the payers like we do, and they can’t always get timely and accurate information from the payers the same way we can, which ends up making those services much less helpful.” says Erin Bishop, the Billing Manager at Associated Retinal Consultants.

This “monkey-in-the-middle” problem boils down to two factors that pharma market access teams currently lack: instant visibility into the obstacles practices and patients face in accessing physician-administered drugs, and leverage to help them address those issues before they spiral. A unified platform for prior authorization submission and tracking, like SamaCare, not only helps lessen the burden of prior authorization process inefficiencies on providers, but also empowers pharma market access teams with more holistic and immediate visibility into the status of prior authorizations submitted for their drugs. With better information and a more embedded position within existing prior authorization workflows, pharma market access teams would have more leverage to improve the process for providers. 

What actions could pharma access and reimbursement teams take if they were more entrenched in the prior authorization workflow? To begin, pharma access teams could help provide practices with forewarning if anything is missing from submission documentation based on a more universal understanding of payer requirements and common errors that lead to delayed or denied prior authorizations. With better data on the average time to approval across different payers for their drugs, pharmaceutical access and reimbursement teams could proactively follow up on prior authorizations that are delayed. With real-time access to prior authorization approval status, access and reimbursement teams could also more expediently help providers address and respond to denials. 

Providers and pharmaceutical market access teams share a common goal: to enable patient access to treatment. Pharma’s traditional approach — phone-based manual support — has made incredible progress to protect patient access, and will continue to play a key role going forward. However, prescribing complexity and prior authorization burdens, especially for physician-administered drugs, continue to increase. By adopting technologies that improve their visibility into access challenges and leverage to solve them, pharmas will be able to achieve a better HCP experience while ensuring the right patients get the right drugs at the right time.