‘Prior auth’ requirements remain a stumbling block for specialty meds


Physicians say the administrative burdens can ultimately affect patient outcomes

For years, the drumbeat has grown over the prior authorization (PA) requirements that payers impose on physicians who prescribe a wide range of medications, mostly in the specialty arena. Even as a number of organizations have sprung up to help the flow of paperwork, many physician offices have hired staff just to handle that paperwork. Now, a market study by SamaCare, a San Francisco company founded in 2018 to address PA issues, finds that physicians remain unsatisfied with available resources.

According to the survey (of 50 practices, ranging from rheumatology to oncology, and mostly in community practices):

  • 96% of providers agree consistent prior authorization denials/delays would impact likelihood to prescribe if there was an equally effective alternative in market.
  • 92% of providers say the prior authorization process has a negative or somewhat negative impact on patient care.
  • 86% of providers say the prior authorization process has a negative or somewhat negative impact on patient outcomes.

Perhaps of most frustration to pharma product managers who have funded market access efforts, while the majority of providers (78%) are aware of market access and reimbursement services, the majority (58%) also only occasionally, rarely, or never engage the assistance of pharma market-access teams. The majority (60%) of providers indicate these teams are at best occasionally helpful, and often not at all.

Syam Palakurthy, cofounder and CEO of SamaCare, notes that hub service providers often step in to expedite the PA process, but they suffer from what he calls the “monkey in the middle” problem: the service provider doesn’t originate the PA, and only learns from the prescribing physician when (and if) the PA has been granted. That puts the burden on the physician office to respond to both the initiation and finalization steps in the PA process.

To address these issues, companies such as SamaCare are building IT systems and cloud-based databases that can integrate with the workflows of many common electronic health-record (EHR) systems at physician offices, and which have up-to-date information from payers. SamaCare reports that its service is free to physician offices; the company can offer what it calls premium information services on pharma brands, for a fee to the manufacturer.

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