Patient Perspective on Prior Authorization Anna Hyde, Vice President - - PowerPoint PPT Presentation

Patient Perspective on Prior Authorization

Anna Hyde, Vice President of Advocacy and Access Arthritis Foundation

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Arthritis Patient Experience with PA

The Issue

• AF survey shows prior auth as the top health care challenge every year
• Contributes to overall administrative burden
• 48% spend more than 5 hours a month managing health coverage, 17% spend more

than 15 hours a month

• Focus groups show across-the-board frustration at complexity of health system and constant

policy changes without clear communication The Impact

• Delays in treatment
• Stress and anxiety
• In some cases abandoning therapy
• Administrative-driven decision making

40%

Ac c e ss Issue s I mpa c ting Pe o ple with Arthritis

32% 24% 30% 29% 21% 28% 34% 32% 26% 29% 28% 28% 26% 16% Prio r Cha ng e s to Hig h Hig h c o - Ste p the ra py a utho riza tio n drug fo rmula ry de d uc tib le insura nc e fo r (F a il first) me dic a tio ns 2017 2018 2019

In their own words

“Our daughte r was diagnose d with juve nile ar thr itis. We ’ve had diffic ulty ge tting thr

• ugh insur

anc e pr ior author izations for c hange s in biologic s and have also had to de al with ste p the r

• apy. T

he r e ar e de finite ly things we c hoose not to do as a family be c ause of the time and c osts of me dic al e xpe nse s.” “I have RA and PsA. E ve r y time my body de c ide s that a c e r tain me dic ine will no longe r wor k, the r e is a wait for pr ior author ization and the n I usually have to take

• ne day to c onne c t my r

he umatologist, the phar mac y, and my insur e r to str aighte n it out.” “My physic ian de c ide d the biologic me dic ation I was on was not wor

• king. It took ove r six we e ks

be for e a ne w biologic was appr

• ve d. T

he pain le ve l r e quir e d I r e tur n to pr e dnisone , whic h c ause s

• the r

issue s, suc h as we ight gain, thinning of bone s, inte r r upte d sle e p and highe r blood gluc ose le ve ls. I e nde d up ne e ding a painful pr

• c e dur

e to r e duc e the buildup of fluid in my kne e . I c an’t he lp but think if I had gotte n the ne w me dic ation appr

• ve d soone r

, I would have be e n able to avoid this painful pr

• c e dur

e .”

zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Our Policy Position on Prior Authorization

The Arthritis Foundation worked with the American Medical Association and other provider groups to establish twenty-one prior authorization principles, including:

• Establish a single, standardized form for physicians to submit prior authorization requests
• Establish electronic systems for the submission of prior authorization requests
• Require prior authorization requests to be completed by insurers within 48 hours of submission or receive automatic approval
• Once approved, permit authorizations to remain in place for up to 12 months for people with chronic conditions, such as

rheumatoid arthritis (RA)

• If a prior authorization request is denied, the member must be given clear instructions on how to file an appeal, the

information required and deadlines

• Provide a process for expedited appeals, especially for urgent care services
• Health plans should offer providers/practices at least one physician-driven, clinically based alternative to prior authorization,

such as but not limited to “gold-card” or “preferred provider” programs or attestation of use of appropriate use criteria, clinical decision support systems or clinical pathways

A.

What Patients Want

• Streamlined process with online tracking capability
• Online portal to file and manage claims; would reduce admin burden for patients and providers
• Faster response times, especially for drugs the patient is already taking
• Transparency about the process from the beginning all the way through
• 95% of survey respondents want to know which medications will require prior auth before its prescribed
• 75% of survey respondents want transparency every step of the way, not just when approved or denied
• Patients want relevant contact info and a step-by-step process on how to file an appeal
• Clear, reasonable explanations for denials