Adult SCD Patient Prior Authorization Outcomes by Pharmacy Reimbursement Specialist

Presentation Date: 6/9/2024 Presentation Start Time: 1:30:00 PM Background Sickle cell disease (SCD) represents a complex and often debilitating hematologic disorder characterized by chronic pain episodes and significant healthcare utilization. The management of SCD-related pain frequently necessitates the use of analgesics, particularly opioids, both for acute crises and chronic pain management. However, the process of obtaining prior authorizations (PAs) for reimbursement of these medications presents a substantial administrative burden for healthcare providers and patients alike. Despite this challenge, many SCD programs lack dedicated pharmacy personnel specifically trained to streamline the PA process, leading to inefficiencies, prolonged wait times, and dissatisfaction among both patients and healthcare providers. This study investigates the outcomes of integrating a pharmacy reimbursement specialist into the VCU adult sickle cell clinic to manage PAs with a focus on optimizing patient care and improving healthcare outcomes. Methods A retrospective analysis was conducted to evaluate the outcomes of authorization processes submitted by the pharmacy reimbursement specialist for SCD-related medications. Data was collected from November 2019 to October 2022 and included PA request and response records submitted by the VCU SCD Medical Home reimbursement specialist. CoverMyMeds served as the primary PA processing platform, while Redcap was utilized for record-keeping and data management. The study population consisted of SCD patients who had submitted at least one PA request during the study period. A total of 848 prior authorization records were initially identified, with 526 records meeting the inclusion criteria for analysis. Approval and denial rates were assessed, along with medication-specific approval frequencies and the distribution of PAs across different insurance providers. Additionally, we performed Chi-square tests to assess the correlation between medications and approval rates, and between insurance providers and approval rates. The significant level was set at p = 0.05. Results The analysis revealed an overall approved prior authorization rate of 78.33%, indicating successful reimbursement for the majority of PA requests. Among the various medications prescribed for SCD-related pain management, Oxycontin emerged with the highest approval rate (87.27%), while Exjade/Jadenu exhibited the lowest approval rate (50%). Insurance provider analysis indicated that Anthem, the predominant Medicaid CMO insurer, had the highest approval rate (92.99%), underscoring variations in PA approval rates among different payors. Chi-Square tests indicated that both insurance providers and medication type affected the approval rate significantly (p < 0.05). Conclusions Our results show that the overwhelming majority of submitted prior authorizations were approved. The majority of submitted and approved requests were for opioids, with Anthem emerging as the payer with the highest approval rate. Anecdotally, the pharmacy reimbursement specialist expertise has boosted workflow efficiency, eased provider workload, and bolstered patient satisfaction. Future research should explore the long-term effects of prior authorization by a reimbursement specialist on healthcare outcomes and resource use in SCD management.