June DTR Analysis: Uncovering administrative barriers
An opportunity exists for managed healthcare executives to help physicians go beyond the typical barriers to accessing certain medications, according to Richard G. Stefanacci, DO, founding executive director of the Health Policy Institute at the University of the Sciences in Philadelphia.
“These are most often barriers in the form of an administrative requirement. But plans also use financial benefits, usually on patients again to limit access,” Dr. Stefanacci says.
“First, an opportunity to move from a barrier system to one that-through an active medication therapy management system-assists prescribers in getting the right medication to the right patient. This would result in higher percentage of plans focusing on reducing adverse side effects through appropriate prescribing.”
Second, he says, there’s an opportunity to move from fax and phone to a point-of-care system as e-prescribing becomes more common. “Currently it’s done through a fax sheet that requires the physician or their staff to answer clinical questions,” Dr. Stefanacci says.
Finally, given that the Medicare Prescription Drug Benefit allows plans to exclude from coverage certain medications as well as off-label use, there will be an opportunity to use prior authorization to assure that these non-covered medications are not paid for, according to Dr. Stefanacci.
“For example, Megace [megestrol acetate] is covered when used for cancer,” he says.
“Plans use prior authorization to assure it's not used for weight gain, which is excluded for Part D coverage. Neurontin [gabapentin], which is used off-label will be subject to prior authorization so they can limit their coverage to labeled-use only.”