Impact of implementing electronic prior authorization on medication filling in an electronic health record system in a large healthcare system

OBJECTIVE Medications frequently require prior authorization from payers before filling is authorized. Obtaining prior authorization can create delays in filling prescriptions and ultimately reduce patient adherence to medication. Electronic prior authorization (ePA), embedded in the electronic health record (EHR), could remove some barriers but has not been rigorously evaluated. We sought to evaluate the impact of implementing an ePA system on prescription filling. MATERIALS AND METHODS ePA was implemented in 2 phases in September and November 2018 in a large US healthcare system. This staggered implementation enabled the later-implementing sites to be controls. Using EHR data from all prescriptions written and linked information on whether prescriptions were filled at pharmacies, we 1:1 matched ePA prescriptions with non-ePA prescriptions for the same insurance plan, medication, and site, before and after ePA implementation, to evaluate primary adherence, or the proportion of prescriptions filled within 30 days, using generalized estimating equations. We also conducted concurrent analyses across sites during the peri-implementation period (Sept-Oct 2018). RESULTS Of 74 546 eligible ePA prescriptions, 38 851 were matched with preimplementation controls. In total, 24 930 (64.2%) ePA prescriptions were filled compared with 26 731 (68.8%) control prescriptions (Adjusted Relative Risk [aRR]: 0.92, 95%CI: 0.91-0.93). Concurrent analyses revealed similar findings (64.7% for ePA vs 62.3% control prescriptions, aRR: 1.03, 95%CI: 0.98-1.09). DISCUSSION Challenges with implementation, such as misfiring and insurance fragmentation, could have undermined its effectiveness, providing implications for other health informatics interventions deployed in outpatient care. CONCLUSION Despite increasing interest in implementing ePA to improve prescription filling, adoption did not change medication adherence.

[1]  Laney K. Jones,et al.  Medications requiring prior authorization across health insurance plans. , 2020, American Journal of Health-System Pharmacy.

[2]  T. Mark,et al.  The effects of antihypertensive step-therapy protocols on pharmaceutical and medical utilization and expenditures. , 2009, The American journal of managed care.

[3]  A. Kimball,et al.  Examining the prior authorization process, patient outcomes, and the impact of a pharmacy intervention: A single-center review. , 2019, Journal of the American Academy of Dermatology.

[4]  Matthew H. Rim,et al.  Implementation and impact assessment of integrated electronic prior authorization in an academic health system. , 2020, Journal of the American Pharmacists Association.

[5]  Ashish K. Jha,et al.  Health Care Spending in the United States and Other High-Income Countries , 2018, JAMA.

[6]  D. Berwick,et al.  Changing the Game of Prior Authorization: The Patient Perspective. , 2020, JAMA.

[7]  L. Casalino,et al.  US physician practices versus Canadians: spending nearly four times as much money interacting with payers. , 2011, Health affairs.

[8]  Victoria A. Shaffer,et al.  The effect of defaults in an electronic health record on laboratory test ordering practices for pediatric patients. , 2013, Health psychology : official journal of the Division of Health Psychology, American Psychological Association.

[9]  Christine Y. Lu,et al.  Unintended Impacts of a Medicaid Prior Authorization Policy on Access to Medications for Bipolar Illness , 2010, Medical care.

[10]  S. Seabury,et al.  Formulary restrictions on atypical antipsychotics: impact on costs for patients with schizophrenia and bipolar disorder in Medicaid. , 2014, The American journal of managed care.

[11]  L. Happe,et al.  A Systematic Literature Review Assessing the Directional Impact of Managed Care Formulary Restrictions on Medication Adherence, Clinical Outcomes, Economic Outcomes, and Health Care Resource Utilization , 2014, Journal of managed care & specialty pharmacy.

[12]  Jeffrey K Aronson,et al.  A new taxonomy for describing and defining adherence to medications. , 2012, British journal of clinical pharmacology.

[13]  George Loewenstein,et al.  Enhanced active choice: A new method to motivate behavior change , 2011 .

[14]  M. Mcclellan,et al.  Streamlining and Reimagining Prior Authorization Under Value-Based Contracts: A Call to Action From the Value in Healthcare Initiative’s Prior Authorization Learning Collaborative , 2020, Circulation. Cardiovascular quality and outcomes.

[15]  C. Vogeli,et al.  Primary Medication Non-Adherence: Analysis of 195,930 Electronic Prescriptions , 2010, Journal of General Internal Medicine.

[16]  Jong-deuk Baek,et al.  Impact of Information Technology, Clinical Resource Constraints, and Patient-Centered Practice Characteristics on Quality of Care , 2015, Health services research and managerial epidemiology.

[17]  M. Ward,et al.  Retrospective database analysis of the impact of prior authorization for type 2 diabetes medications on health care costs in a Medicare Advantage Prescription Drug Plan population. , 2015, Journal of managed care pharmacy : JMCP.

[18]  J. Steiner,et al.  Standardizing Terminology and Definitions of Medication Adherence and Persistence in Research Employing Electronic Databases , 2013, Medical care.

[19]  M Alan Brookhart,et al.  The Epidemiology of Prescriptions Abandoned at the Pharmacy , 2010, Annals of Internal Medicine.

[20]  Sameer Malhotra,et al.  Effects of an e-Prescribing interface redesign on rates of generic drug prescribing: exploiting default options , 2016, J. Am. Medical Informatics Assoc..

[21]  M. Fischer,et al.  A randomized telephone intervention trial to reduce primary medication nonadherence. , 2015, Journal of managed care & specialty pharmacy.

[22]  C. Morley,et al.  Practice characteristics and prior authorization costs: secondary analysis of data collected by SALT-Net in 9 central New York primary care practices , 2014, BMC Health Services Research.

[23]  J. Resneck.  Refocusing Medication Prior Authorization on Its Intended Purpose. , 2020, JAMA.

[24]  Anita C. Murcko,et al.  Medication prior authorization from the providers perspective: A prospective observational study. , 2019, Research in social & administrative pharmacy : RSAP.

[25]  Dylan S. Small,et al.  Using Default Options Within the Electronic Health Record to Increase the Prescribing of Generic-Equivalent Medications , 2014, Annals of Internal Medicine.

[26]  M. Rosenthal,et al.  How Primary Care Physicians Integrate Price Information into Clinical Decision-Making , 2016, Journal of General Internal Medicine.

[27]  Xiaonan Xue,et al.  Estimating the relative risk in cohort studies and clinical trials of common outcomes. , 2003, American journal of epidemiology.

[28]  R. Glynn,et al.  Association Between Patient-Centered Medical Homes and Adherence to Chronic Disease Medications , 2016, Annals of Internal Medicine.

[29]  J. Steiner,et al.  Health Care System-level Factors Associated With Performance on Medicare STAR Adherence Metrics in a Large, Integrated Delivery System , 2015, Medical care.