If Gwen Goldfarb, our chapter executive, or I can be of assistance to you, please let us know.

Sincerely,

The burden of prior authorizations (PAs) on healthcare delivery and patient access is likely well known to the members of the Ohio-ACC. The growing impact of prior authorizations has become a focus for groups such as the American College of Cardiology, the American Medical Association, and the American Heart Association. The AHA launched a Value in Healthcare Initiative to work on four priority areas to improve cardiovascular care delivery: value-based models, partnering with regulators, predict and prevent, and prior authorization. Some of the solutions proposed, like value-based contracts which relax or bundle PAs, or a shift in utilization management from a payer to a health system, are novel but may require active participation from both payers and prescribers¹.

A meeting organized by the Academy of Managed Care Pharmacy to discuss the PA process for PCSK9 inhibitors showed the importance of these communications between payers and providers². The AMCP surveyed payers and providers before and after the meeting. After the meeting, payers decreased in their belief their PA criteria accurately distinguished patients (72%-50%), became more agreeable to less stringent PA criteria (33%-72%), and recognized the need for standardized processes (50%-83%). Over 80% of participants, both in payer and provider groups, supported programs to educate staff on PA processes.

One solution that has gained more visibility in the last few years has been the electronic prior authorization process. Despite the increased implementation of electronic prior authorization processes, a 2020 report by CoverMyMeds revealed that 49% of practices still utilize non-electronic methods of submitting prior authorizations³. Data suggests a prospectively initiated (i.e. in-office) electronic prior authorization can substantially improve time to medication access, on average 13.2 days sooner. Unfortunately, CoverMyMeds found only 17% initiate a PA at the point of prescribing. The challenge facing clinicians is balancing the administrative burden of initiating the proactive PA with their patient care responsibilities.

The Center for Medicare and Medicaid Services (CMS) finalized a new rule at the beginning of 2021 to improve upon the electronic prior authorization (PA) process⁴. One of the more notable changes highlighted by CMS was a requirement for payers to establish a standardized system for sharing health data between payer-to-provider and payer-to-payer. Another notable change was a requirement to reduce the PA decision time to a maximum of 3 days for urgent requests and a maximum of 7 days for non-urgent requests. Unfortunately, these rules only apply to Medicaid and not Medicare Advantage plans, which limits the impact of these rules. These rules are a step forward, but there is still a considerable need to lower barriers, improve transparency on decisions, and improve patient access that solutions proposed by the AHA Value in Healthcare Initiative may address.

The Ohio-ACC continues to maintain a resource page dedicated to the prior authorization process. Visit this link, and if you have any feedback or requests to improve upon this resource, please contact the Ohio-ACC.

The American College of Cardiology is currently offering FREE ONE YEAR MEMBERSHIP to all new CV Team members until 8/31/2021! Unlocking free membership is easy. All your nonmember colleagues need to do is complete a quick ACC membership application at https://memberapp.acc.org/, and enter promo code CVTREFER20 on the payment screen. Their free membership will extend through December 31, 2021.