Stakeholders from across the health care spectrum came together to discuss pragmatic solutions to improving the prior authorization process as it pertains to prescribing cardiovascular medications as part of ACC’s Prior Authorization: Right Drug, Right Patient For Cardiovascular Treatment Roundtable on Oct. 12.

Roundtable Co-Chairs Dharam J. Kumbhani, MD, FACC, and Lonny Reisman, MD, FACC, kicked off the day-long event by talking about the importance of having the “right treatment for the right patient at the right time,” yet current prior authorization requirements for cardiovascular drugs pose significant challenges to achieving this goal. A recent ACC survey showed that 78 percent of respondents consider prior authorization and the associated documentation a heavy administrative burden and one of the greatest barriers to providing the benefits of new therapies to patients. Moreover, less than one-third of patients prescribed a PCSK9 inhibitor received the medication due to low insurance approval rates and patient abandonment, according to a study recently published in JAMA Cardiology.

“It’s evident that the status quo is not working – having transparency in the process is appreciated by everyone and we need to work together to identify a common denominator that all stakeholders can use,” said Kumbhani.

Pamela B. Morris, MD, FACC, associate professor of medicine and director of the Seinsheimer Cardiovascular Program and co-director of women’s heart care at Medical University of South Carolina, was joined by Amita Dasmahapatra, MD, senior director of medical affairs at CVS Health, during an interactive discussion on “why prior authorization.” Morris and Dasmahapatra offered their perspectives as a provider and as a pharmacy benefits manager, respectively, on the need to define the goal of prior authorization – to stem overutilization or improve optimization? From there, participants discussed ways to streamline the documentation process; the value of qualitative vs. quantitative measures in prior authorization criteria; usefulness of the appeals process; appropriate use of step therapy; and more.

Alan Balch, PhD, CEO of the National Patient Advocate Foundation and the Patient Advocate Foundation, and Lauren Vela, MBA, senior director of member value for the Pacific Business Group on Health, tackled the many ways real-life complexity and costs impact prior authorization over both the short-term and the long-term. Their insights were followed by in-depth debate around whether patients can/should be partners in the prior authorization process and whether there are ways to determine patient costs before the process begins. The role of pharmacoeconomics, copays and deductibles, medical assistance programs and guidelines were also examined.

Will data save the day, or are data another complication? Evan Grossman, vice president of integration services for athenahealth, and Luke Forster-Broten, MA, manager of product innovation at Surescripts, engaged with attendees on the topics of data use and role of electronic health records (EHRs), as well as the role of analytics and data acquisition. Their presentations focused on whether the prior authorization process could be integrated and automated using EHRs, allowing the prescribing physician and the pharmacy access. Additionally, Nicole Darden, from the ACC’s PINNACLE Registry team, provided an overview of how data registries could be leveraged to not only flag medications requiring prior authorization, but also to understand changes in cardiovascular care.

“The nature of this discussion is unique and hopefully this uniqueness will bring solutions,” noted Reisman during his closing remarks. Richard J. Kovacs, MD, FACC, chair of ACC’s Science and Quality Committee, said it’s the College’s hope that the Roundtable “will shape pragmatic solutions that the ACC can leverage to inform the development of resources and tools to support effective prior authorization of cardiovascular drugs.”

This Prior Authorization Roundtable was part of the Heart House Roundtables. It was supported by Amgen, Bristol-Myers Squibb, Pfizer, Janssen and Sanofi Regeneron.

Keywords: Patient Care, Cardiovascular Diseases, Cardiovascular Agents, Health Planning, Registries, Health Resources

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