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David Choi, Amy Lawando, Monika K Lach, Health-system specialty pharmacies do the heavy lifting for hospital electronic medication prior authorizations, American Journal of Health-System Pharmacy, Volume 79, Issue 17, 1 September 2022, Pages 1405–1406, https://doi.org/10.1093/ajhp/zxac134
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Prior authorization (PA) is a tool utilized by insurers to control costs. It was developed during the 1990s to ensure patients received the most appropriate medications, procedures, and tests while reducing waste and unnecessary costs.1 For medications, the aim was to avoid inappropriate drug use and promote evidence-based therapy. Along with PAs, insurers implemented restricted formularies, tiered systems, step therapies, and quantity limit strategies to control costs.1
Since the initial conception of PA, the associated burden has increased substantially. PA requests for Medicare Part D plans increased from 8% (2007) to 24% (2019).1 Given the rising cost of new biologics and advanced therapies that have entered the market, PAs for 4 therapeutic classes (antineoplastic drugs, multiple sclerosis agents, autoimmune disease immunotherapies, and antidepressants) have increased noticeably from 35% (2011) to 67% (2016).1 According to the 2020 American Medical Association PA Physician Survey, 30% of physicians claim that the PA process has resulted in a significant medical event, such as hospitalization, a life-threatening incident, or death.2 The PA process has been shown in 90% of cases to have a negative impact on patient care, with 66% of prescriptions rejected at the pharmacy due to PA requirements.2 With 40% of physician staff having to work exclusively on PAs, the administrative cost for physicians in processing PA requests amounted to $528 million in 2019.2
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