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Hospital Site/Name:
UC Health – University of Cincinnati Medical Center, Cincinnati, Ohio 234 Goodman Street
Cincinnati, OH 45219
Advanced Role Title:
Prior Authorization Technician
Team Members:
Timmi Anne Boesken, MHA, CPhT, Medication Access Services Coordinator, Pharmacy Services; Alaina Chou, PharmD Candidate 2019; Jason Fletcher, PharmD, Transitions of Care Pharmacist, Outpatient Pharmacy Services; Kimberly Hausfeld, CPhT, Pharmacy Technician II, Outpatient Pharmacy Services; Thia Iverson, CPhT, Pharmacy Technician II, Outpatient Pharmacy Services; and Kathryn McKinney, PharmD, MS, BCPS, FACHE, FASHP, Director, Pharmacy Services
Primary Intended Outcomes:
- Creation of advanced role opportunities for certified pharmacy technicians to expand the scope of pharmacy services.
- Efficiently manage prior authorizations to ensure access to medications through the efforts of dedicated pharmacy technicians.
- Increase the capability of the pharmacist to focus on direct patient care and patient counseling while optimizing patient adherence, outcomes, and satisfaction.
Relevant PAI Recommendations:
D1: A critical component pharmacy departments should implement to optimize pharmacy practice models include:
D1a: Opportunities for pharmacy technician role expansion to broaden the scope of pharmacy services.
D2: Implementing a pharmacy technician driven prior authorization process allows the pharmacist, providers, and support personnel to spend more time on direct patient care activities.
Situation Analysis:
With goals to improve the quality and cost of healthcare in the United States, constant changes in the healthcare environment have increasingly made it difficult for providers to ensure their patients receive the prescribed medications. Prior authorizations are a common barrier for providers. In a 2017 survey conducted by the American Medical Association, 41% of physicians stated they received a decision on their submitted prior authorizations in two to five business days and seven percent of physicians stated they waited greater than five business days for a decision. Ninety-two percent of physicians reported prior authorizations resulted in delayed necessary care for patients. Ninety-one percent of the physicians suggested potential for negative impact on patient clinical outcomes as an implication of prior authorizations. In the survey, 86% of physicians reported the burden of prior authorizations has increased over the past five years.
In the time waiting for a prior authorization decision, adverse effects to critically ill patients may occur including the delay in receiving their medication and potentially requiring an additional or longer hospital stay. Insurance companies often require prior authorizations for non-formulary medications, high-cost medications or medications exceeding standard dosages. If the patient has failed first line therapy options or has a contraindication to the insurance formulary product, a prior authorization is required to obtain an alternative medication. Prescriptions requiring the use of higher doses than typically recommended in the guidelines often require a prior authorization. Scenarios in which a third-party insurance company requires further explanation of the medication use, dosage, and/or quantity prescribed to confirm appropriateness requires time to submit the prior authorization. This time leads to interruptions for the provider and delay in medication access for the patient.
After discussions with various clinic providers that acknowledged patients difficulties receiving initial access to medications because of varying practices at outside pharmacies, it was determined there was an opportunity to help patients. To effectively streamline the process and ensure access to these medications, pharmacy services completed the prior authorizations for the targeted medications. The successful process change led to a shift in the practices of UCMC outpatient pharmacy department in December 2016. The pharmacy department took ownership of the prior authorization process for our hospital-based providers. Using UCMC Hoxworth Outpatient Pharmacy resources, specifically incorporating certified pharmacy technicians, the prior authorization process could be expedited allowing providers to focus on direct patient care. The unique alignment of the pharmacy allows communication of the required information on specific medications, dosage forms, or quantities that may be above the usual guideline recommendation or is of high cost when compared to an alternative medication option with insurance companies and third-party providers.
Advanced Role Description:
Pharmacy technicians serve as patient advocates by assisting patients in obtaining their medications as part of the Transitions of Care team. Pharmacy technicians play a vital role in the patient care process as they have the pharmacy knowledge, training, and understanding to collaborate with clinical pharmacy staff, providers, and support personnel to identify medications early on that may require further assistance in obtaining approval. The goal is to provide adequate time to process the prior authorization to ensure the patient is able to obtain their medication. The role of the pharmacy technician is to assist in bridging the gap between prescribers and pharmacy by eliminating the need for providers and support staff to process prior authorizations as well as improving patient access to medication. The advantage of this team is their access to the electronic medical record system and the connections to the clinical pharmacy specialists as well as healthcare providers and support personnel. The staff members are able to justify the medication prescribed by, for example, providing documentation from the provider’s note in the electronic medical record stating the patient failed other therapies or by providing lab values that show the patient has a contraindication to the preferred medication. These efforts are thought to lead to increased patient adherence and satisfaction which subsequently results in an improved quality of life as well as patient outcomes.
Key Elements for Success:
- Support from the hospital administration for the expansion of pharmacy technician roles in Transitions of Care.
- Due to the complexity of prior authorizations, early identification is key. Leveraging resources like clinical pharmacists, providers, and support personnel to notify outpatient pharmacy of potential medication barriers allows for adequate time to receive a determination from third-party insurance companies.
- Provide adequate training to pharmacy technicians to ensure an understanding of the process as demonstrated through a prior authorization competency test.
- A systematic approach should be applied when submitting prior authorizations to ensure processes align with standard work: documentation of initiating team member, key code used to identify the prior authorization, and expectations for follow-up.
- A dedicated workspace for pharmacy technicians.
Revenue and Expense Parameters (abbreviated financials as applicable):
Direct expenses include the salary and benefits of the certified pharmacy technician. Additionally, the technician’s workstation set up includes a computer, phone, printer, access to the electronic medical record (EMR), office supplies, utilities, etc. To ensure patient access, prior authorizations are completed for patients regardless of if they can be filled within the UC Health network of retail pharmacies. Since December 2016, approximately 3,000 prior authorizations have been submitted resulting in:
- Dispense of 1,500 prescriptions through UC health retail pharmacies
- Additional revenue of $743,150
Resource Utilization:
- Personnel: This program initially began with two certified pharmacy technicians and is overseen by one dedicated pharmacist. As the program grew, the team expanded with the additional training of: five cross-trained pharmacists, four certified pharmacy technicians, and three pharmacy interns. Through a rotational schedule, one FTE is distributed among these trained individuals. The service is available eight hours a day, seven days a week.
- IT and Other Infrastructure: Prior authorizations are performed using desktop computers, access to the electronic medical record, and utilization of CoverMyMeds.
- Supply Expense: This program includes the use of desktop computers, telephones, copiers/fax machines, and office supplies.
- Return on Investment: Approximately 1,500 prior authorizations have been completed and dispensed resulting in additional revenue of $743,150 for UC Health retail pharmacies as well as increased prescription count.
Recognized Intangible Benefits:
Prior authorizations can delay the medication use process and lead to worsening symptoms and outcomes if a patient is unable to be compliant with their medication regimen. Utilizing hospital resources to expedite the prior authorization process can help decrease hospitalization, morbidity, and mortality. The success of the program at University of Cincinnati Medical Center is demonstrated through improved time to prior authorization approval, increased medication access, and improved patient adherence. Pharmacy ownership of prior authorizations also allows the physician to dedicate more of their attention to direct patient care subsequently improving provider and patient satisfaction.
Outcome Measures:
- Number of prior authorizations submitted including resubmissions and appeals (3,059)
- Percentage of prescriptions filled and dispensed by a UC Health retail pharmacy (49%)
- Revenue generated ($743,150)
- Time to determination (95% = 24 hours)
Lessons Learned:
- Strong communication between clinical pharmacy specialists, providers, and support personnel with outpatient pharmacy is vital in expediting the medication use process.
- Highly trained pharmacy technicians can significantly improve the prior authorization process and thus medication access as well as contribute to patient adherence, outcomes, and patient satisfaction.
Other Considerations:
All organizations should ask who is the owner of the prior authorization process currently and what is the workflow. Create a strategic plan to incorporate prior authorizations in pharmacy workflow.
Suggestions for Other Hospitals/Health Systems:
Start with one clinic or office to build success and then expand. Engage leadership to restructure the prior authorization process through pharmacy. Candidate selection for the Prior Authorization Technician should consider the individual’s knowledge, experience, communication, and organizational skills. Each technician should train closely with an experienced pharmacist and display competency upon concluding training.
Helpful References:
- 2017 AMA Prior Authorization Physician Survey. American Medical Association. 2018.
- Hospital national patient safety goals. Elements of performance for NPSG.03.06.01.
https://www.jointcommission.org/assets/1/6/NPSG_Chapter_HAP_Jan2018.pdf