There is a spotlight trained on the constant tug of war currently ongoing between payer and manufacturers regarding at-risk negotiations and drug costs. In the background, pharmacists are frequently left solo to handle the prior authorization and to ensure patient access to necessary medication.
According to a November 2015 report from The Pew Charitable Trusts, Specialty Drugs and Health Care Costs, in 2014, less than 1% of all prescriptions were written for specialty drugs, yet these drugs accounted for approximately 32% of total drug expenditures.
Specialty then vs. specialty now. The hard truth is that “specialty” use to mean drugs complex to manufacture, administer and patient-monitor. Now the term refers more broadly to the most costly drugs. The fact that patients are now experiencing reduced access to medication due to payer resistance in the form of a significantly more burdensome prior authorization approval process comes as no surprise. As stated in a previous post, prior authorizations are here to stay and the process is not getting simpler by any measure.
In addition to the increase in the sheer number of drugs requiring prior authorizations, some prior authorization forms have reached 10 pages in length. Imagine being the clinician, or clinical administrator, handed that ‘form’ and having to choose between taking hours to complete the administrative task or serving more patients. It’s a situation the collective industry has created because it behaves more like a demolition derby instead of a relatively organized Sprint Cup race.
Adapting to prior authorization complexities. For now, it seems as if the best course of action is for specialty pharmacies to invest in additional patient support – a prior authorization pharmacist - to alleviate some of the stress of processing prior authorizations and reauthorizations. This new class of pharmacists will have to possess a clinical skill set to work through the intricate prior authorization process and a meticulous, tenacious nature for securing medication payment approval for as many patients as possible.
Interested in learning more? Read Curant COO Marc O’Connor’s article on cultivating specialty pharmacists in Specialty Pharmacy Times.
Want to continue the conversation on the role pharmacists and medication management play in delivering value-based healthcare? We’d love to hear from you! Send us an email.
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