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Myndshft Blog

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November 27, 2023

HIV & AIDS: How Prior Authorization Software Creates Smoother Care Pathways

by Susan Lawson-Dawson | Healthcare Technology, Prior Authorization

In 1988, December received the designation of HIV/AIDS Awareness Month in the U.S., coinciding with the United Nations’ World AIDS Day on December 1st. Since the peak of the HIV / AIDS epidemic in the 1980s, the CDC says annual infections have declined by more than two-thirds. While the decline represents a significant positive trend, roughly 1.2 million Americans still live with HIV. More unfortunately, new infection rates highlight ongoing health inequities. For example, the CDC notes that: 

  • African Americans (12% of US population) account for 40% of new HIV infections
  • Hispanic/Latinos (18% of US population) account for 29% of new HIV infections
  • Caucasians (61% of US population) account for 26% of new HIV infections

The fact that 52% of newly diagnosed individuals live the the South reflects a disproportionate burden based on regional disparities.

Experts attribute it to the combined result of ongoing racial and socio-economic health inequities prevalent in the South, as well as greater stigma associated with LGBTQ individuals than in other areas of the nation. This contributes to making the path from diagnosis to treatment for HIV/AIDS even more ponderous for patients and providers alike. Identifying and understanding barriers is not just about getting through the paperwork. It helps ensure that life-saving treatments reach patients without undue delay. How does prior authorization software remove complexity and put patients on the right track to manage an HIV or AIDS diagnosis? 

Deep Dive: Prior Authorization under Pharmacy and Medical Benefits

At its core, public and private payers use prior authorization as a tool to control costs and ensure appropriate care. While prior authorizations serve a purpose, they often clash with the pressing needs of HIV/AIDS care.

  • Pharmacy Benefits: When a medication is prescribed, especially one that’s high-cost or has potential for misuse, insurers may require a prior authorization. This is to ascertain its necessity and its alignment with the insurer’s formulary. For HIV/AIDS patients, many of whom require antiretroviral therapy (ART), this can mean navigating multiple layers of authorization, especially for newer, potentially more effective drugs.
  • Medical Benefits: Beyond medications, HIV/AIDS patients often need specialized services like laboratory monitoring, viral load testing, and consultations with specialists. Prior authorization for these can be equally intricate because the ordering provider and servicing provider may differ. 

Healthcare Finance reports that 94% of physicians report that prior authorizations delay access to necessary care. In the realm of HIV/AIDS—where timely intervention can mean the difference between effective viral suppression and potential complications—these delays are particularly concerning.

Juggling Care with Current Bureaucracy of Medical & Pharmacy Prior Authorizations

Every hour a provider spends on prior authorization is an hour less on direct patient care. Beyond the administrative drain, this can have serious repercussions:

  • Patient Outcomes: Even a slight delay in initiating or modifying ART can lead to viral resistance, making treatment less effective in the long run.
  • Provider Burnout: The American Medical Association notes that administrative tasks like prior authorization are a significant contributor to physician burnout, impacting the overall quality of care.

Incorporating technology offers an alternative to muddled, manual prior authorizations. Prior authorization software, for example, offers several compelling advantages:

  • Data Integration: A unified platform for medical and pharmacy prior authorizations can seamlessly pull data from electronic health records (EHRs), payers and pharmacy benefit managers (PBMs), helping ensure that the right forms are populated with up-to-date and accurate patient and provider information.
  • Ongoing Monitoring: Real-time alerts can inform providers if there’s an issue with a submission, like an additional question set needed by a PBM. The alert can also provide a timeframe for submission, allowing for timely action so the prior auth ball keeps rolling. 
  • Efficient Workflows: Built to understand the nuances of different insurers’ requirements, a robust prior authorization platform guides providers through the most efficient path to approval.

It’s estimated that automating the prior authorization process could save up to $454 million annually, illustrating the significant economic potential of this approach.

Proactive Steps Lead to Smoother Prior Authorization Path

What can you do to facilitate timely prior authorization submissions and reduce preventable denials that keep patients from needed care? 

  • Stay Informed: Ensure you’re updated on the latest guidelines for HIV/AIDS care and how they align with insurance requirements. Organizations like the HIV Medicine Association offer valuable resources.
  • Advocate for Change: Join collective efforts by medical associations, LGBTQ resource centers, and health equity foundations to streamline or reform the prior authorization process and address disparities regardless of the cause. 
  • Leverage Technology: If you haven’t already, explore and invest in prior authorization software tailored for your practice’s needs.

Ready to escape the prior authorization maze? With well-informed strategies and appropriate technological support, you can navigate prior authorizations more efficiently, freeing your time for patient care instead of paperwork. Prioritizing patient needs and staying abreast of evolving solutions is crucial in the ever-important mission of delivering timely and effective HIV/AIDS care. Together, we can make it happen. 

Myndshft is here to help. Let’s talk!