October 4, 2023
Rebates, Discounts, and Formularies: How PBMs Shape Medication Access & the Benefits of Automating Prior Authorizations for Pharma and Medical Benefits
by Susan Lawson-Dawson | Healthcare Technology, Prior Authorization
As professionals deeply involved in patient care, understanding the complex dynamics of medication access represents a pivotal aspect of your role. Prescription medications are often the cornerstone of treating numerous health conditions, but how these medications are priced, accessed, and distributed can be enigmatic, to say the least. Some medications fall under medical benefits, such as injection or infusions of biologics for rheumatoid arthritis. Others, those self-administered by the patient, fall under pharmacy benefits. That’s where Pharmacy Benefit Managers (PBMs) enter the picture. This adds yet another layer to the already complicated world of prior authorizations, which often serves as… Read entire article here
Pharmacy Benefit Managers (PBMs) originated during the 1960s in response to the growing complexity of drug benefit programs within health insurance plans. Initially, PBMs’ primary role was to process prescriptions and handle the administrative burden for insurers. As the healthcare landscape evolved, so too did the responsibilities of PBMs, expanding to include drug formulary management, pharmacy network contracting, and drug utilization reviews. And of course, PBMs began using prior authorization to further manage costs. Is it any wonder that providers want a way to automate prior authorizations to relieve the administrative burden? That's where a prior authorization platform offering unified… Read entire article here
You can’t talk about transforming healthcare in the US without talking about prior authorization. There. We said it. Of course, we aren’t alone. Politicians, providers, payers and patients all recognize problems with prior authorization. It’s not surprising, then, that intelligent prior authorization earned a spot on the GartnerⓇ Hype Cycle for Healthcare Payers in 2023. How does intelligent prior authorization differ from the status quo? Currently, the typical prior authorization process is manual or a clunky combination of manual and electronic steps that acts as a bottleneck in patients’ care journeys. By using natural language processing, artificial intelligence, and HL7Ⓡ… Read entire article here
In the dynamic landscape of healthcare, inefficiencies cost everyone time and money. When it comes to prior authorization, those shortcomings contribute to friction between payers like you and your networks of healthcare providers and members. In an Op-Ed in Becker’s Hospital Review, Northwell Health President & CEO Michael J. Dowling wrote, “To sustain our delivery system, the future of healthcare must include productive partnerships between providers and payers. Without increased cooperation, we'll continue to be adversaries and everyone, including patients, will suffer.” As with Goldilocks and the Three Bears, the key to success lies in finding the “just right” balance… Read entire article here
