Transcript Presentation Slides

The Electronic Prior
Authorization (ePA)
Ecosystem:
Connectivity Between
Pharmacists, Providers
and Health Plans
Perry Lewis, VP of Industry Relations,
CoverMyMeds
Matt Moore, MBA, Senior Strategist,
Clinical Solutions, Cerner Corporation
About NCPDP
Founded in 1977, NCPDP is a not-for-profit, ANSI-accredited, Standards
Development Organization with over 1,600 members representing virtually
every sector of the pharmacy services industry.
NCPDP members have created standards such as the Telecommunication
Standard and Batch Standard, the SCRIPT Standard for e-Prescribing, the
Manufacturers Rebate Standard and more to improve communication within the
pharmacy industry.
Our data products include dataQ®, a robust database of information on more
than 76,000 pharmacies, and HCIdea®, a database of continually updated
information on more than 2.3 million prescribers. NCPDP's RxReconn® is a
legislative tracking product for real-time monitoring of pharmacy-related state
and national legislative and regulatory activity. www.ncpdp.org
About CoverMyMeds
Founded in 2008, CoverMyMeds is the nation’s largest and most connected
electronic prior authorization (ePA) solution. We help patients receive the
medication they need to live healthy lives by automating the prior authorization
(PA) process, saving health care professionals valuable time and reducing
prescription abandonment.
CoverMyMeds integrates directly within prescriber and pharmacists’ existing
workflows as well as with health plans and payers to allow for near immediate
determinations. More than 700,000 providers and more than 49,000
pharmacies currently process ePA requests through the CoverMyMeds web
portal, as well as via their electronic health record (EHR) or pharmacy system
vendor. Our technology integrates with more than 500 EHR vendors, 80 percent
of pharmacy system vendors and payers representing 75 percent of U.S.
prescription volume. Providers using our solution successfully process more
than 1.6 million PA requests every month. www.covermymeds.com
About HIMSS
HIMSS North America, a business unit within HIMSS, positively transforms
health and healthcare through the best use of information technology in the
United States and Canada. As a cause-based non-profit, HIMSS North America
provides thought leadership, community building, professional development,
public policy, and events. HIMSS North America represents 64,000 individual
members, 640 corporate members, and over 450 non-profit organizations.
Thousands of volunteers work with HIMSS to improve the quality, costeffectiveness, access, and value of healthcare through IT. Major initiatives
within HIMSS North America include the HIMSS Annual Conference &
Exhibition, National Health IT Week, HIMSS Innovation Center, HIMSS
Interoperability Showcases™, HIMSS Health IT Value Suite, and ConCert by
HIMSS™.
HIMSS Vision: Better health through information technology.
www.himss.org
Perry Lewis, VP of Industry Relations,
CoverMyMeds
Perry is Vice President of Industry Relations for
CoverMyMeds, with a focus on pharmacy
association engagement and leading advocacy
efforts in both the state and federal arena pertaining
to electronic prior authorization (ePA). He is also the
chair of NCPDP Board of Trustees.
Perry has spent more than 30 years successfully
managing relationships in the PBM and independent
and chain pharmacy environment supporting
community pharmacy initiatives, initiating strategy
for network development and product management.
He is actively involved in state and federal health
care advocacy roles. He previously worked for
McKesson AccessHealth as AVP PBM Relations
contracting and supporting development of networks
for independent chains.​
Matt Moore, Senior Strategist, Clinical
Solutions, Cerner Corporation
Matt is responsible for leading the strategic
direction in the Orders and ePrescribing
solutions at Cerner. He has performed this
role in various capacities and with various
solutions since joining Cerner in 2003. Matt is
a member of NCPDP and involved in several
task groups helping to define key standards
and lead the industry towards utilization of
best practices.
Matt holds a B.A. and MBA, with emphases in
Information Technology and Marketing, from
the University of Kansas as well as
certifications as a Pharmacy Technician
(CPhT) and Project Management Professional
(PMP).
Accreditation Statement
• The Institute for Wellness and Education, Inc., is accredited by
the Accreditation Council for Pharmacy Education (ACPE) as a
provider of continuing pharmacy education. Participants of the
session who complete the evaluation and provide accurate NABP
e-Profile information will have their credit for 1.0 contact hours
(0.10 CEU) submitted to CPE Monitor as early as 14 days after
the event and no later than 60 days of the event. Please know
that if accurate e-Profile information is not provided within 60
days of the event, credit cannot be claimed after that time. The
participant is accountable for verifying accurate posting of CE
credit to their CPE Monitor account within 60 days.
• ACPE program numbers are:
0459-0000-17-023-H04-P and 0459-0000-17-023-H04-T
• Initial release date for this program is 1/24/2017.
Learning Objectives
• Define the current state of ePA availability and adoption
across pharmacies, EHR vendors and payers that
represent the majority of market share
• Differentiate between availability and adoption among
industry players
• Distinguish the relationship and methodology of ePA
between the medication prescriber and pharmacist
• Identify states that have legislation surrounding
electronic submission of PA requests
Pre-test Questions
1. What types of prior authorization management
methods are available?
2. What health plans do you encounter most often for
your patients?
3. Does your state have a mandate in place requiring
a standard PA processing method?
Prior Authorization, Defined
Prior authorization (PA) is a requirement that your physician obtains approval from your health
insurance plan to prescribe a specific medication for you. PA is a technique for minimizing costs,
wherein benefits are only paid if the medical care has been pre-approved by the insurance company.
PA is typically required due to quantity limits, step therapy, non-formulary medications and expensive
specialty drugs.
Issue with Prior Authorization:
Prior to electronic prior authorization (ePA), a prior authorization
required a fax based workflow to be completed by the provider and
staff. Each health plan/PBM having their own set of unique
requirements.
Impact on Medication Adherence:
40% of medications requiring prior authorization are abandoned once
rejected at the pharmacy
The Prior Authorization Problem
$
Daily hassle for
healthcare providers and
pharmacies
250+ Million
prescriptions rejected
per year
Multi-billion dollar
impact, industry-wide
Administrative Waste
More than 50% of providers indicate
that they and their staff spend up to 20
hours per week on PA requests
Pharmacists spend an average of 5
hours per week on PA requests
Prescriber Costs by the Numbers
Nationwide, physicians
spend $37 billion annually
interacting with health
plans. Much of that cost is
directly related to prior
authorization and
medication formulary
requirements.
Medication Non-Adherence
Medication non-adherence costs more than $100 billion a year in excess.
Nearly 30% of
prescriptions written are
never picked up
75% of patients fail to
take medications as
prescribed
Causes of Prescription Abandonment
Characteristics of
the Disease State
Dosing schedule
Medication Side-effects
Cost of medications
•
Co-pay
•
Insurance restrictions
•
Prior Authorization
•
Quantity Limit Restrictions
•
Step Therapy Requirements
•
Non-formulary
Abandonment and Readmission
• The nearly one in five Medicare patients
return to the hospital within a month of
discharge alone costs nearly $20 Billion
per year
• The number of medications a patient is
discharged with directly correlates with
the likelihood they will be readmitted to
the hospital within one month
• Medication adherence is at the core of
readmission prevention plans for health
systems
The Hospital score as a predictor of 30 day admission: retrospective study at university affiliated community hospital
NEHI Improving Medication Adherence and Reducing Readmissions
Abandoned Prescriptions
Recent studies reflect 265 million claims a year result in prior authorization requests.
Based on Frost & Sullivan study
Completion and Turnaround Times
Completion
Turn Around Time
PRE-ELECTRONIC
ELECTRONIC FAX
ePA
15-20 Minutes
3-5 Minutes
Web: 3-5 Minutes
EHR: Seconds
3-5 Days
2-4 Days
Approved: Real-time
Denied: <24 Hours
Electronic Prior Authorization (ePA)
RETROSPECTIVE
PROSPECTIVE
AL L PAY E R
Ability to receive PA
requests started by a
pharmacy
Allows prescriber to start
a PA request in
E-Prescribing workflow
Supports completion of
PA requests for any
health plan or PBM
ePA Workflow: Retrospective
Initiates Request
Completes Request
Call CP!
Electronic
Connection
Pharmacy
Prescriber or
Staff
Plan/PBM
ePA Workflow: Prospective
Initiates and Submits
Request at Point of Prescribing Call CP!
Electronic
Connection
Prescriber or
Staff
Plan/PBM
Pharmacy
NCPDP SCRIPT Standard
ePA Stakeholders
EHR Vendors:
Allows prescribers to initiate an ePA request at the point of prescribing
PBMs and Health Plans:
Allows for faster PA determinations for providers and eliminates the form
selection process
Pharmacy System Vendors:
Allows pharmacists to initiate ePA requests in their dispensing system at
the time of claim rejection, automatically notifying the prescriber to
review and submit the request to the plan
ePA Adoption by Stakeholder
EHR AVAILABILITY
Available
Committed
5% increase from Q1 2015
16% increase from Q1 2015
Live
25% increase from Q1 2015
PBM AVAILABILITY
Committed
Available
20% increase from Q1 2015
1% increase from Q1 2015
Live
8% increase from Q1 2015
PHARMACY AVAILABILITY
Committed
13% increase from Q1 2015
Available
15% increase from Q1 2015
Live
5% increase from Q1 2015
Cerner’s ePA Story
Cerner today
1299465778_CernerOverviewWidescreen_v16 Updated: 7/1/16
© Cerner Corporation. All rights reserved. This document contains Cerner confidential and/or proprietary information belonging to Cerner Corporation and/or its related affiliates which may not be reproduced or transmitted in any form or by any means without the express written consent of Cerner.
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Why ePA Made Sense To Invest
 The traditional PA Process is inefficient for all stakeholders
•
•
•
•
Utilizes fax/ phone workflows
Not integrated in patient record
Requires dedicated resources in some cases
Long processing and response times
 Inconvenient for patients
•
•
Patients unable to pick up prescription at pharmacy upon arrival
Linked to significant prescription abandonment
 The traditional PA process is ripe for disruption
 State Regulations quickly moving in support of standardized
PA process
Why ePA Made Sense to Invest
 NCPDP standards established and gaining maturity
 Support from other stakeholders beyond early adopter to near
critical mass
•
No “chicken or the egg” problem
Key Design Considerations
 How deeply integrated do you need ePA to be in application?
•
•
Native allows for more control, but longer development roadmap and time
to market
ePA “Plug-In” approach provides less control of development, but faster
time to market
 How is ePA integrated in the prescriber and support staff’s
workflows?
•
•
•
•
How will provider be made aware a PA may be needed?
Who manages PA transactions? Who will ultimately be addressing ePA
forms?
How is the patient notified of PA status?
How is electronic routing of prescription impacted by ePA process?
Factors Driving Adoption
ePA availability within EHR
system vendors
States mandating electronic
PA submission
Payers directing providers to
electronic PA solutions
State Mandates
Active Legislation
Pending Legislation
Legislation Inactive or Dead
No Current Legislation
Legislation Key Takeaways
26 states have a law pertaining to prior authorization. Of those, eight
states require the use of the nationally recognized NCPDP SCRIPT
Standard when utilizing ePA.
Seven states—Connecticut, Delaware, Missouri, New Jersey, New York,
Ohio, and West Virginia—have pending legislation, three of which
recommend the use or consideration of the NCPDP SCRIPT Standard.
Payers as Key ePA Participants
Fast
Reduces manual PA reviews
through auto-determination
Efficient
Eliminates phone calls and
faxes for prescriber
Secure
HIPAA compliant and follows NCPD
SCRIPT standards
Accurate
Intelligent analytics provide better
data and on-demand reports
Payer Success Driving Adoption
In Q4 2013 a large, regional health plan serving nearly 4 million members engaged
with CoverMyMeds to implement and launch a fully integrated electronic prior
authorization (ePA) solution with the following objectives:
Generate provider adoption of an ePA solution
to gradually shift all prior authorization (PA)
submissions to an electronic process.
Automate all components of the
PA workflow including intake,
processing and notifications.
Improve efficiencies by enabling
real-time application of specified
criteria and determinations at the
point of prescribing.
Solution
Working in conjunction with the plan, CoverMyMeds implemented CoverMyMeds Central, a
proprietary ePA solution for pharmacy benefit managers (PBMs) and health plans.
CoverMyMeds Central Features: Central intake, workflow management, autodetermination, processing, claim adjudication, notification and system updates
Provider Adoption Tactics: Call center training and scripting, prescriber fax and
email campaigns, online demonstrations for providers and public relations efforts
Results
Specialty Volume
There is a direct correlation between
the availability of specialty and new
medications and a rise in PA volume.
As more specialty medications enter
the market the industry will see an
increase in the need for PA requests.
CoverMyMeds Data
Spending Increases
In 2014, more than $124 billion was spent on specialty medication, a $54
billion increase since 2009.
New medication accounted for $20
billion, or 47%, of total medication
spending growth in 2014.
Modern Healthcare, April 2015
2017 Technical Innovation for ePA
IntelligentPA: Innovation for the pharmacist, based on historical data
a PA request is automatically initiated when it is most likely to be
required.
Clinical Alerts: Allows pharmacists to provide
face-to-face consultation with the patient about
a potentially high-risk medication while staying
within their workflow by alerting them of a
counseling opportunity.
Post-Test Questions
1. What is an electronic prior authorization?
a) An electronic form that is generated based off
rejection type, the patient, plan and the medication.
b) A general paper form that contains nonspecific
questions
c) A form that must be called in directly to the insurance
plan
d) None of the above
Post-Test Questions
1. What is an electronic prior authorization?
a) An electronic form that is generated based off
rejection type, the patient, plan and the medication.
b) A general paper form that contains nonspecific
questions
c) A form that must be called in directly to the insurance
plan
d) None of the above
Post-Test Questions
2. True or false: Electronic prior authorization
submission works for specialty medications.
a) True
b) False
Post-Test Questions
2. True or false: Electronic prior authorization
submission works for specialty medications.
a) True
b) False
Post-Test Questions
3. Which states have mandates regarding PA?
a) California
b) Minnesota
c) Iowa
d) All of the above
Post-Test Questions
3. Which states have mandates regarding PA?
a) California
b) Minnesota
c) Iowa
d) All of the above
Post-Test Question
4. What are the benefits of electronic prior
authorization?
a) Decrease in prescription abandonment
b) Real time responses
c) Increase in therapeutic outcomes
d) All of the above
Post-Test Question
4. What are the benefits of electronic prior
authorization?
a) Decrease in prescription abandonment
b) Real time responses
c) Increase in therapeutic outcomes
d) All of the above
Post-Test Questions
5. Which of the following is not a participative user of
electronic prior authorization solutions?
a) health plans
b) patients
c) providers
d) pharmacists
Post-Test Questions
5. Which of the following is not a participative user of
electronic prior authorization solutions?
a) health plans
b) patients
c) providers
d) pharmacists
Questions?
Save the Date
• Tuesday, February 14 | 12:00pm – 1:30pm CT/1:00pm – 2:30pm ET
Integrated Electronic Prior Authorization (ePA) Solutions: Electronic Health
Records, Pharmacy Dispensing System Vendors and Web Portal Options
Electronic Prior Authorization (ePA) has several different workflows. A prior
authorization (PA) request can be initiated prospectively at the point of prescribing
within electronic health record (EHR) systems, retrospectively upon a claim rejection
at the pharmacy within the dispensing system or within a web portal option allows for
both prospective and retrospective PA management. This second webinar of the
series will provide a deeper dive into what implementing an integrated ePA solution
entails and how tools like web portals play a part in this process.
• Tuesday, March 28 | 12:00pm – 1:30pm CT/1:00pm – 2:30pm ET
Best Practices for Electronic Prior Authorization (ePA) Implementation and
Adoption: Eliminating Barriers to Workflow Integration for Pharmacists and
Providers
Although the manual prior authorization (PA) process is outdated, tedious and filled
with overhead expenses, adopting the optimal electronic method can be challenging,
just like implementing any new technology can be. The last webinar of the series
will discuss barriers to changing pharmacists’ and providers’ normal workflow and
strategies for rolling out a new process in your pharmacy or practice.
Save the Date
HIMSS17
HIMSS’s annual conference and exhibition will be held
February 19-23, 2017. We hope to see you in Orlando. For
more information on HIMSS17, please visit
www.himssconference.org.
NCPDP17 –
40th Anniversary Conference
NCPDP’s annual technology & business conference will be held
May 8-10 in Scottsdale, AZ. For more information, please visit
www.ncpdp.org.