Prior Authorization Reform Is A Welcome Concept for Long-Term Care

Filling prescription medications for patients in long-term care environments, particularly for elderly or complex patient populations, can be challenging not only because of the complexity of diagnoses but because of the added layer of prior authorization.

Introduced by the health insurance industry as a way to help control costs and flag the administration of any inappropriate or unnecessary medication, the prior authorization process extends to medical services, too. The process, however, has become objectively burdensome for providers and can lead to delays in treatment or access to pharmaceuticals that a patient needs.

Now, a number of stakeholders in the healthcare community are looking for reform that will make the process easier, reduce the amount of tedious paperwork the process requires, and shorten the time that it takes to receive prior authorization.

As with any substantive systems change, effective reform of the prior authorization process would likely come with its own set of challenges.

A recent article published in the New England Journal of Medicine tackled the issue by looking at both sides — highlighting potential challenges and opportunities to prior authorization reform. The article came in response to a recent proposal by the Centers for Medicare and Medicaid Services to streamline the electronic prior authorization process exclusively for medical services within the Medicare Advantage program. Notably, the proposal excluded reform for prescription drug prior authorization, an area of healthcare — the article noted — could benefit from reform.

The call for reform included four priorities to maximize adoption among providers. They included: 

  • A system that did not require additional costs for providers
  • A system that is universal for all payers
  • A system that offers real-time intelligence and transparency
  • A system that is electronic and integrates with EHRs

And at UnitedRX, we can’t disagree with the need for this type of reform. As it pertains specifically to long-term care, where the average prescription load for individual patients jumps from 13 between the ages of 50 and 64 to 22 for those aged 80 and older. 

More swift responses from payers would be helpful, as would a reduction in the administrative paperwork that is required for prior authorization requests. And, a universal system would seemingly benefit every stakeholder, from provider to pharmacist to patient to payer. 

Reform takes time and advocacy, which we understand.

However, it’s heartening to not only consider reform but see others within the industry call for and take action to initiate reform, including the American Medical Association and some individual states such as California, New York and Michigan. 

It’s possible the CMS proposal to streamline electronic prior authorization for medical services just for Medicare Advantage is a stepping stone for greater change across the industry. After all, the Kaiser Family Foundation reports that 99% of Medicare Advantage members are enrolled in plans that require prior authorization for some services — which is to say that specific landscape of patients is fertile ground for a proposed change. 

Of course, time will tell. Standardizing and investing in systems change is a massive undertaking. But a system built to deliver care when it is needed may require that type of commitment to ensure patients, providers and pharmacists are able to effectively prescribe, deliver and receive treatment.

At UnitedRX, we deliver a hometown pharmacy experience to more than 400 clients across the country. Contact us to learn more about how our approach to treatment can meet the pharmacy needs of your long-term care facility.