Medication prior authorization from the providers perspective: A prospective observational study

The prior authorization (PA) process for medications used by community providers requires modernization. Therefore, a deeper understanding of current state of PA from the community provider perspective is imperative to inform and modernize this managed care tool.

Objectives of this study were to identify, analyze and categorize the issues associated with the medication PA process from provider practice perspective.

A prospective non-experimental, cross sectional, observational study was performed using semi-structured interviews and direct observation at a convenience sample of eight primary care and medicine subspecialty group practices in Tucson, Arizona, USA. Participating practices were required to have an established medication PA process. The participant feedback from each site was analyzed using the Richards qualitative coding technique that includes descriptive coding, topic coding, and analytical coding.

Data were obtained from eight unique community provider offices (8 sites) at which 29 prescribers practice. The pain points identified represented five main categories: 1) information transfer gaps; 2) format disparities; 3) outdated technologies; 4) care consequences; and 5) workarounds. Prescribers and their staff suggested improvements that included real time eligibility and formulary alerts regarding PA during the e-prescribing process, accurate, up-to-date formulary data with easy-to-access alternatives, and embedded PA that is integrated with electronic medical record data. Three sites used medication PA portals such as CoverMyMeds^® for information gathering, but at the time of data collection, no sites used these PA portals for prospective electronic prior authorization (ePA) or the electronic process of requesting authorization from health plan payers for coverage.

The PA process for medication used by community providers is in urgent need of modernization. Pain points identified in this study could be alleviated by implementing medication ePA solutions. However, providers and their staff are largely unaware that ePA exists. Additional research in this area is needed.