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

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 zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA The Impact Ac c e ss Issue s I mpa c ting Pe o ple with Arthritis 40% • Delays in treatment 34% 32% 32% 30% 29% 29% 28% • Stress and anxiety 28% 28% 26% 26% 24% 21% • In some cases abandoning therapy 16% • Administrative-driven decision making 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. “My physic ian de c ide d the biologic me dic ation I We ’ve had diffic ulty ge tting thr ough insur anc e pr ior was on was not wor king. It took ove r six we e ks author izations for c hange s in biologic s and have also be for e a ne w biologic was appr ove d. T he pain had to de al with ste p the r apy. T he r e ar e de finite ly le ve l r e quir e d I r e tur n to pr e dnisone , whic h c ause s things we c hoose not to do as a family be c ause of othe r issue s, suc h as we ight gain, thinning of the time and c osts of me dic al e xpe nse s.” 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 oc 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 ove d soone r , I would have be e n able to “I have RA and PsA. E ve r y time my body de c ide s that avoid this painful pr oc e dur e .” 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 one 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.”

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

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 A.