Section 02: Impact & Adoption

Now that ePA is readily available for all stakeholders, it is important to reflect on the value a solution brings to patients and providers while identifying and overcoming challenges to provider adoption.

Impact and adoption header image

Patient Impact

Approximately 11 percent of prescription claims are rejected at the pharmacy, and, on average, 66 percent of those prescriptions require PA; furthermore, 37 percent of those prescriptions will be abandoned due to the complex paper-based process.6

Such prescription abandonment increases the risk of future health problems or hospitalization for the patient. The utilization of an electronic solution may increase patient medication adherence by helping to ensure patients leave the pharmacy with prescription in hand.

Effect of PA Completion Channel on Dispense Rate

Improvement in patients’ perception of access to medications can increase the probability that they will pick up their prescriptions and adhere to the therapy.

Turnaround times on PA determinations through ePA are on average much shorter than those through traditional channels (i.e. phone and fax) leading to 80 percent higher dispense rates in some cases and a 3 percent greater likelihood that patients will pick up their prescriptions.7, 8, 9

With a reliable ePA solution, turnaround times for PA determinations can be on average 35 percent shorter as reported by a major pharmacy benefit manager.9 Data from a large ePA vendor reveals that completing PA requests electronically has a dramatic effect on determination time versus the fax channel.7

* Determination rate calculated as percent of PA requests that receive a determination from a health plan in a given timeframe over total requests submitted to plan

† Based on thousands of ePA and fax transactions

A medication is more likely to be dispensed (i.e. picked up by the patient) if turnaround time for the PA process is short. Indeed, the dispense rate for a medication can be dependent on the channel used to complete PA requests (i.e. fax versus ePA). Not only can the phone and fax channel for PA delay medication dispense by a full day, the dispense rate for medications is on average 5 percent less relative to ePA.8

* Dispense rate calculated per diem as dispensed claims tied to a PA request (submitted electronically or by fax) with an approval determination from a health plan over total PA requests (submitted electronically or by fax) with an approval determination from a health plan.

† Magnitudes of prescriptions dispensed when PA requests are completed by ePA or fax channels are not reported here, only dispense rate when an approved determination is available through either channel.

‡ Based on thousands of ePA and fax transactions

Not only can accelerated turnaround times on ePA determinations affect dispense rates at the pharmacy, the improved patient perception of access to medications can translate to a 3 percent greater likelihood that patients will pick up their prescriptions from the pharmacy9 — of the 4.5 billion prescriptions filled per year,10 this equates to nearly 30 million more patients getting their medication when a PA is required. As more providers begin to adopt ePA, more patients may adhere to their medications.

Provider Impact

Providers view PA as a significant burden that draws attention away from delivering patient care. Electronic prior authorization was developed with providers in mind to reduce the administrative burden imposed by PA.

In a recent survey, 1,453 providers outlined the most challenging aspects of PA. When asked about the greatest benefits of ePA, provider responses addressed many of the reported challenges plaguing the PA process.11

PA Challenges*

66% - Time consuming

48% - Takes away from patient care

38% - Lack of answers to form questions

31% - Lack of insurance information

27% – Cannot find the correct PA form

ePA Benefits*

70% – Faster determinations

69% - Time savings

65% - Ease of use

54% - Organization of PA requests

* Percentages reflect those who selected these individual options.

Provider Perception

Despite availability of ePA and its demonstrated efficacy to save time and money, research shows that providers use the burdensome phone and fax channel more than 50 percent of the time to complete PA requests.2

A recent direct-to-provider survey shines light on why providers are not using ePA more often.11

Among approximately 1500 surveyed providers currently using ePA, more than half reported occasionally using non-electronic methods (i.e. phone and fax) to complete PA requests for certain situations, including:

Topic Perception Reality
Specialty Medications Some providers are not aware of ePA as a solution for specialty medication PA requests. Electronic prior authorization is already available and being utilized by providers for many specialty medications.
Urgent Requests Even though phone calls with payers can take significant time, providers perceive they can get a determination more quickly (i.e. by the end of the call). As an industry, we know this is not the case as most ePA request are made instantly with little or no wait time for an outcome.
Specific Insurance Plans Some payers may not have all lines of business available for ePA functionality; ePA is not available for specific plans (e.g. Medicaid and Medicare Part D) Leading ePA vendors have all payer capabilities such that providers can quickly find, complete and submit PA forms for any insurance plan electronically via a web portal.
Extenuating Circumstances For difficult cases, providers feel limited by electronic forms and perceive a phone call as easier for explaining complicated patient scenarios. Leading ePA vendors have functionalities that allow for document attachment (e.g. patient history, lab results, etc.) and dynamic fields that simplify the PA process as much as possible for any situation.
Key Takeaway

Key Takeaway

Communicating the value of ePA to providers is critical for driving adoption and success. The ability of ePA to save time and administrative costs as well as contribute to positive patient outcomes through reduction in time to therapy must be continually expressed. Understanding factors that promote or limit providers from engaging with ePA solutions is important for overcoming limitations of the technology and crafting new outreach strategies to influence provider adoption.