News
Article
Pharmacy-Led Prior Authorization Model Reduces Delays and Improves Patient Care
Author(s):
A pilot program integrated oncology pharmacists into prior authorization workflows to streamline and expedite medication approvals.
Prior authorization (PA) remains a significant challenge in oncology care, creating administrative burdens for health care providers and delaying access to critical treatments for patients. At the ACCC 51st Annual Meeting & Cancer Center Business Summit, Andrea Ledford, PharmD, MBA, BCOP, BCSCP, FASHP, FHOPA, senior pharmacy director of oncology services at Orlando Health Cancer Institute, shared a pilot program at her institution that sought to address these inefficiencies by integrating the oncology pharmacy team into the PA process. The results demonstrated a marked improvement in clinic efficiency, reduced physician burden, and better patient outcomes and highlighted the crucial role of pharmacists at every point in the patient care continuum.1
Prior authorization form on desk | Image Credit: © piter2121 - stock.adobe.com
PA is intended to optimize patient outcomes, reduce errors and waste, and decrease unnecessary drug costs, but studies indicate that it often acts as a barrier to timely care for patients. A JAMA article found that the average length of time for PA approval has increased to approximately 14 days, with 91% of physicians reporting negative clinical outcomes and 82% observing patient treatment cessation. Notably, 22% of patients do not receive their prescribed therapy at all.2
These delays present challenges for health care staff as well. PAs can increase administrative burdens on clinics, causing delays that reduce streamlining and operational efficiency. This lends to heightened anxiety among both staff and patients as they attempt to navigate complex, burdensome PA processes within busy clinic settings.1
"The physicians are frustrated," said Ledford. "I don’t want our physicians stuck on the phone arguing with the insurance company as to why a patient needs a specific drug for lung cancer."
To combat these challenges, Ledford and her team developed a pilot program that leveraged AI to increase the use of prospective PAs, leading to improved clinic efficiency, reduced physician workload, and streamlined medication approval. Under the new system, pharmacy technicians were trained to use the electronic medical record (EMR) system and facilitate communication between clinic staff and payers. The approach focused on using prospective PA rather than the traditional retrospective method, which allows for speedier treatment approval.1
"With prospective PA, we can get approvals within 24 hours before the prescription even leaves the cancer center," Ledford explained. "That was our goal."
Ledford shared that there was some initial reluctance among nurses to relinquish control of the PA process, but the pharmacy team worked to build trust and ensure a seamless transition. This was done through the handling of insurance-specific protocols, troubleshooting approval delays, and securing necessary documentation. The program expanded to cover 28 clinics with just 2 full-time pharmacy technicians, later growing to 36 clinics and continuing to maintain the same staffing levels.1
Prior to the intervention, the control group had a 93.5% approval rate, which increased to 97.4% after shifting PA responsibilities to the pharmacy team. The change also alleviated clinic congestion and reduced wait times, creating a smoother experience for patients and staff, eliminating inefficient downtime, and enhancing overall operational efficiency.1
"Patients were stuck in exam rooms while staff were on the phone," said Ledford. "Now, they get their medications faster, and the clinics run more smoothly."
Additionally, there were improvements in staff retention, according to Ledford. In the pilot program, pharmacy technicians were given the option to work remotely after an initial 6-month training period in the clinics, allowing them to establish themselves and build comfortability within their team and roles prior to transitioning to a work-from-home setting.1
"I haven’t had anyone leave the pharmacy tech team in 18 months," the expert noted. "They have an axe to grind with the payers too, so they’re motivated to push things along."
Building on this success, the program is continuing its efforts by focusing on streamlining the peer-to-peer review and appeal processes, particularly for targeted therapies. Clinical pharmacists have been brought into the workflow to create structured documentation, allowing for better tracking of payer decisions and denials. However, new challenges continue to emerge. Some payers now require peer-to-peer reviews for all drugs approved under expedited FDA pathways, which account for approximately 95% of new oncology medications. Additionally, insurers are imposing dose rounding protocols, effectively dictating treatment decisions to physicians.1
"They're not just telling us what drugs to use anymore; they're telling us what doses to prescribe," the expert observed.
The integration of the pharmacy team into the PA process has proven to be an effective strategy for improving efficiency and reducing physician burden. The transition to a pharmacy-led model not only enhanced communication within clinics but also led to tangible benefits for both providers and patients. As the healthcare landscape continues to evolve, pharmacy-driven solutions offer a promising approach to tackling administrative challenges and ensuring timely access to essential treatments.1
"It was an advantage for the pharmacy team, the clinic team, and most importantly, the patients," Ledford concluded. "Everyone benefits when we remove these barriers to care."
