1. Targeted Prescriber Office Outreach to Grow Adoption of
Electronic Prior Authorizations
AUTHORS: Leo Rudawsky, PharmD Candidate; Lynne Nowak, MD; David Lawrence, PharmD; Becky Leacock, MA
AUTHOR AFFILIATION: Express Scripts Holding Company, St. Louis, MO, USA
ABSTRACT:
PROBLEM DESCRIPTION: Electronic prior authorizations
(ePAs) enable rapid, streamlined processing of prior
authorizations (PA) resulting in decreased prescription
turnaround time for prescribers, pharmacies, and patients.
Few factors challenge ePA system implementation such
as delegation of support staff duties and potential workflow
transition and interruption. These surmountable issues
take time, focus and resources away from providing patient
care due to the use of traditional, lengthy methods of
PA submissions. Targeted outreach could help overcome
these challenges.
GOAL: Explore the capacity of targeted outreach to
prescriber offices in driving growth of ePA submissions.
PROGRAM DESCRIPTION: We conducted a retrospective
study using a pre-post case-control analysis. A pharmacy
technician experienced in communicating with physician
offices gathered feedback on the ePA process from
prescribers (case group) associated with three clients of a
national pharmacy benefits manager between March and
May 2016. Brief one-on-one discussions addressing any
concerns that might prevent use of the ePA process were
held with those responsible for submitting ePAs in each
setting. Prescribers associated with the same three clients
that received no outreach from the pharmacy technician
constituted the control group. For each prescriber, total
ePA submission counts were compared before and after
the technician outreach. Monthly rates of ePA utilization
were calculated and compared between the two groups
to obtain the difference in ePA adoption with and without
targeted outreach.
OBSERVATIONS: Based on quarter 1 of 2016 data (prior
to outreach), baseline rates of ePA use for case and control
groups were 26.8% (n=1,687) and 27.3% (n=1,947),
respectively. The case group resulted in a 6.5% increase
of ePA submissions over two months (to 33.3%) while the
control group experienced an increase of 3.6% (to 30.9%).
Overall, this pattern indicates a +2.9 percentage point
increase in ePA adoption over two months.
FINDINGS/RECOMMENDATIONS: Based on the unique
needs of individual prescriber offices, targeted outreach may
serve as a useful form of driving ePA usage. With ePA being
relatively new to the healthcare industry and consequently
underutilized, further research is warranted to better discern
clinical and financial implications of ePA submission growth.
We anticipate greater patient-centric care and subsequent
lower healthcare costs resulting from decreased lost time
in the care continuum while simultaneously closing gaps in
patient therapies due to increased ePA usage.
Problem Description:
Currently, in most cases, prior authorization (PA) requests
are completed through a manual process involving faxes
and phone calls back-and-forth between the pharmacy,
prescriber, and health plan. Resulting inefficiencies in this
process can lead to patients abandoning their prescriptions
and significant loss of time across all players in the
healthcare industry.1
Recent studies indicate 265 million
claims per year are rejected resulting in 74.4 million
abandoned prescriptions.2
Additionally, nearly 40% of PA
requests are abandoned due to complex procedures.3
Market
trends and corresponding utilization management policies
suggest that the number of PA submissions will continue to
rise in the future. For instance, annual specialty medication
spend expanded from $70 billion in 2009 to $124 billion in
2014.4
Data suggests there is a direct relationship between
availability of specialty medications and PA volume, which
implies an increased need for PA requests over time.2
Overall, traditional manual PA processes with corresponding
prescription abandonment and time lost in the continuum
of care appears to be becoming a bigger concern as PA
submissions increase over time.
Electronic Prior Authorizations (ePAs) offer a simple,
integrated, and time-efficient approach to submitting PAs,
which can address and resolve current inefficiencies of the
traditional PA process. For example, ePA completion within
an Electronic Health Record (EHR), can take as little as
seconds, whereas traditional pre-electronic PA completion
lasts anywhere from 15 to 20 minutes. In addition, ePA
turnaround often happens real-time, with traditional PA
methods taking 2-5 business days.2
With this streamlining
of PA requests and subsequent improvement in turnaround
time, ePAs can potentially eliminate many time-related
delays of most customary PA procedures and improve
patient care.
Despite ePA systems being implemented and readily
usable within a prescriber office, certain factors may limit
use of ePA submissions. Because technology platforms
and customary procedures vary across different practice
settings, challenges to adopt and habituate the ePA process
are often unique to each prescriber office. For example,
the responsibility of submitting a PA can span across
multiple staff members, ranging from medical assistants to
administrative specialists, nurses and PA coordinators. This
inconsistency leads to communication obstacles and hinders
learning and understanding of the ePA process which
ultimately results in resorting to traditional inefficient routine.
By and large, unique challenges exist within prescriber
offices which mitigate the utilization of ePA submission
processes. Due to the anticipated increase in use of PAs and
potential advantages of electronic forms of PA submission,
assisting to overcome these hindrances may be of significant
value. Furthermore, a targeted, personalized outreach may
be a more appropriate technique due to the varying level of
specific needs of every individual office setting.
Goal:
Explore the capacity of targeted outreach to prescriber
offices in driving growth of ePA submissions.
Program Description:
Between March and May 2016, a pharmacy technician
contacted prescriber offices associated with three clients
of a national pharmacy benefits manager (PBM). Outreach
occurred over the telephone with detailed documentation
of each encounter recorded by the technician. A script was
followed to ensure the following information was addressed:
• Identity of and conversation with support staff member
allocated for PA submission
– If multiple people responsible, then head nurse or office
manager was contacted
• Open-ended feedback of the ePA system, with responses to
any concerns
• Appropriate fax number to send educational materials
Following each encounter, the technician faxed a document
to the attention of the aforementioned individual. An
instructional leave-behind (Exhibit 1) to assist with the ePA
process was sent, in addition to other materials deemed
useful per feedback during the discussion.
Exhibit 1 Leave-behind document, faxed to the attention
of individual responsible for ePA submissions in each
prescriber office setting.
Research Design: Retrospective pre-post case-control analysis
Inclusion Criteria:
• Prescribers with accessible submission data for both total
and electronic PAs between Jan. and May 2016
• Prescribers who submitted ≥30 PAs between Jan. 1 and
March 31, 2016
• Prescribers who were associated with one of three identified
clients of the national PBM who provided consent
Study Timeline: Eligible PA submissions from prescribers
were identified between Jan. 1 and May 31, 2016
Case Selection: Cases were identified as prescribers which
had received a successful outreach by the pharmacy
technician between March 21 and May 16, 2016
Control Selection: Controls were identified as prescribers
associated with the same three clients that received no
outreach from the pharmacy technician between March 21
and May 16, 2016
Unit of Analysis: Numbers of total PA and ePA submissions
were aggregated at the quarterly and monthly level prior to
and after targeted outreach, respectively
Analysis: In both case and control groups, PA submission
data between Jan. 1 and March 31, 2016 (Quarter 1,
Q1) were aggregated, with pre-intervention ePA utilization
percentage (ePA%) calculated as below (Exhibit 2).
Additionally, post-intervention ePA% was calculated monthly
for April and May 2016.
Exhibit 2 Calculation for ePA utilization percentage (ePA%)
ePA% =
ePA submissions (n)
Total PA submissions (n)
Statistical Test: A two-sided, two-proportion z-test was
performed to determine ePA% trends between the case
and control groups, before and after the outreach. Level of
significance was established with α= 0.05.
Observations:
The final study sample resulted in 138 case prescribers and
164 control prescribers with pre-outreach ePA utilization
values of 26.8% (n=1,687) and 27.3% (n=1,947),
respectively (Exhibit 3). The case group experienced a 6.5%
increase over two months (p0.05), with the control group
experiencing a 3.6% increase (p0.05). Overall, this pattern
indicates a +2.9 percentage point increase in ePA adoption
over two months (Exhibit 4).
Exhibit 3 Total PA and ePA data before (Q1) and after
(May) targeted outreach with calculated ePA utilization
percentages (ePA%) as well as differences between Q1 and
May 2016
Case Group (n=138) Control Group (n=164)
Q1 2016
ePAs (n) 1,687 1,947
Total PAs (n) 6,304 7,130
ePA% 26.8% 27.3%
April 2016
ePAs (n) 452 467
Total PAs (n) 1,437 1,695
ePA% 31.5% 27.6%
May 2016
ePAs (n) 486 518
Total PAs (n) 1,460 1,677
ePA% 33.3% 30.9%
ePA Percentage Point Difference
(May-Q1)
6.5%* 3.6%*
*statistically significant between and within groups (case-control)
Exhibit 4 Two month growth rate difference between case
and control groups
7.00%
6.00%
5.00%
4.00%
3.00%
2.00%
1.00%
0.00%
ePAgrowth%
Control Case
3.6%
6.5%
+ 2.9 percentage points
Limitations:
• The small sample sizes between the two groups could not
lend to multivariate difference-in-difference analysis.
• Targeted outreach was conducted for prescribers
associated with three specific clients of the national PBM,
which could limit the generalizability of the findings to
other settings. Information regarding outside sources of
ePA adoption influence (vendors, health systems, etc.) was
unavailable, which may have confounded results in both
case and control groups.
• Because prior data regarding the time-delay between
targeted outreach and observed effects on ePA% was not
available, results may underestimate the actual influence
of outreach.
• This study focused on aggregate PA submissions and thus
confounders such as individual medication classes and
unique practice settings that may affect ePA adoption
patterns could not be measured.
Findings/Recommendations:
The study findings suggest a significantly growing trend of
ePA submissions, both with and without targeted outreach.
Future studies examining the clinical and financial
implications of this ePA submission growth are warranted
to better elucidate the significance of the observed +2.9
percentage point increase. We anticipate greater patient-
centric care and subsequent lower healthcare costs resulting
from decreased lost time in the care continuum while
simultaneously closing gaps in patient therapies due to
increased ePA usage.
Finally, the benefits of targeted outreach extend beyond
only driving ePA adoption. For example, enhanced one-
on-one contact with prescriber offices allows a platform to
receive high quality feedback on ePA systems and the PA
submission process overall. Future research focusing on
qualitative measures to better analyze the survey feedback
from each encounter may be helpful in bringing these
benefits to light.
References:
1 NCPDP SCRIPT Standard Electronic Prior Authorization Transactions Overview. August 2013. Available at
http://www.ncpdp.org/NCPDP/media/pdf/NCPDP_SCRIPT_ePA_Standard.pdf. Accessed on July 28, 2016.
2 CoverMyMeds ePA National Adoption Scorecard. October 2015. Available at https://epascorecard.
covermymeds.com/. Accessed on July 28, 2016.
3 The Impact of the Prior Authorization Process on Branded Medications: Physician Preference, Pharmacist
Efficiency and Brand Market Share. Available at https://epascorecard.covermymeds.com/images/
FrostSullivanPrior%20AuthorizationWhitepaper%20FINAL.pdf. Accessed on July 28, 2016.
4 Specialty drugs, Medicaid expansion drive jump in prescription spending. April 2015. Available at http://
www.modernhealthcare.com/article/20150414/NEWS/304149967. Accessed on July 28, 2016.