(010) Analysis of Pharmacist Integration in the Prior Authorization Practice Model in an Outpatient Cancer Center

Poster Abstract: Heath insurers use a type of utilization review called prior authorization (PA) to determine medical coverage for individual patients. Authorizations impact providers, payers, and patients by controlling delivery services, payments, and reimbursement amounts for medications. Patients awaiting authorization may experience treatment delays and authorization denials may lead to less favorable treatment options. Healthcare systems may be required to complete time-consuming peer-to-peer reviews to challenge authorization denials. Additionally, healthcare systems may not be fully reimbursed for denied medications already administered to the patient.

Previous studies have shown cost-savings with pharmacy involvement in the PA process. At Monument Health Cancer Care Institute (CCI) a pharmacist is not included in the authorization team. The purpose of this study is to optimize the current PA process at Monument Health CCI by implementing pharmacist assessment of authorization denials. The denials will be reviewed to assess whether pharmacist interventions may improve the efficiency of authorizations and provide cost savings.

This retrospective chart review includes adult patients with an oncology diagnosis and a denial for an oncology-related medication at Monument Health CCI from March 1, 2023 to August 30, 2023. Real-time pharmacist interventions will be made on denials as deemed appropriate. Descriptive statistics will be used to evaluate primary and secondary endpoints.

Study results will provide data regarding potential impact of pharmacist involvement in the PA process based on specific denial trends identified and potential cost-savings from pharmacist interventions. Results will help assess roles for integration of pharmacists into the PA process that would provide the most impact at Monument Health CCI.

References (must also be included in final poster): Trapani D, Kraemer L, Rugo HS, Lin NU. Impact of Prior Authorization on Patient Access to Cancer Care. Am Soc Clin Oncol Educ Book. 2023;43:e100036.

Chen A, Pecoraro F, Bonck M. Developments of a Prior Authorization Practice Model for Outpatient Infusions Clinics. Unpublished Manuscript. 2020. St. Joseph Medical Center, Tacoma, WA.

Britnell SR, Brown JN, Hashem MG, et al. Pharmacy resident involvement in prior-authorization drug request adjudication. Am J Health Syst Pharm. 2018;75(23 Supplement 4): S87-S93.