Streamlining PA Process, Promoting Biosimilars With Automated Informatics

At The James at The Ohio State University Comprehensive Cancer Center (OSUCCC), the use of an informatics program has automated the selection of biosimilars, accounting for a patient’s insurance preferences and that of the hospital, to effectively optimize the prior authorization and approval process.

At the 2024 Association of Cancer Care Centers (ACCC) National Oncology Conference, OSUCCC was one of the Innovator Award recipients, an honor that spotlights programs for their efforts to enhance access, value, and quality in the delivery of cancer care. Implementing this electronic tool at OSUCCC greatly reduced administrative burden and contributed to a 21.9% uptick in biosimilar utilization.

Biosimilars are projected to contribute to 10s of billions in health care savings over the next 5 years | image credit: Photo18@desing - stock.adobe.com

“Biologics are the forefront of medication,” began Sarah Hudson-DiSalle, PharmD, RPh, FACCC, assistant director of reimbursement services, OSUCCC, as she detailed how availability of novel, new therapies has the industry focused on economically developing medications, particularly in the form of biosimilars. Biosimilars are projected to have drastic implications for the future of medical care and costs, with The IQVIA Institute for Human Data Science foreseeing $181 billion in savings over the next 5 years.¹

Costs aside, Hudson-DiSalle continued by praising biosimilars’ ability to drive ingenuity in the field, marketplace competition, and increase drug development; however, the interchangeability of these drugs often poses some challenges. Moving from one agent to another, she mentioned, is often complicated by the process of prior authorization.

Prior authorization has been reported as one of the larger sources of administrative burden for today’s health care professionals.² Hudson-DiSalle pointed to the “step therapy” method that typically arises during this process “where you have to fail with an agent that is preferred by the insurance company before you can use the agent that would be optimal.” This inefficiency is a hindrance to quality care, and she has seen first-hand how this back and forth, increased denials and treatment plan changes frustrate both providers and patients, and lead to delays in patients’ treatment.

To address this issue, a multidisciplinary Steering Committee consisted of leadership from the oncology infusion, prior authorization and revenue, finance, supply chain, and pharmacy informatics departments was assembled around the common goal of reducing administrative burden.

This team developed a calculator tool to optimize payor-driven biosimilar selection. Their calculator incorporates data from their top 25 insurance payers, contractual rates, rebates, and agreements with pharmaceutical companies. Thereafter, a rule-based Advanced Order Group was established that would consider a patient’s primary payor, that payor’s preferred product, and automate a treatment plan. From here, they started a pilot program, selecting 1 agent at a time at a dedicated infusion sight. Half of the prior authorization steps were eliminated during this pilot, and they were able to implement additional biosimilars more widely by 2022.

“The turnaround time for our authorizations went from 12 days down to 4. And so, knowing that we could get that patient in the chair much more quickly than what we were able to before was really transformative for our area and the use of biosimilars."

Looking ahead, this system is set to expand and cover other therapeutic agents and supportive care treatments with the continued aim of reducing delays and manual interventions for providers.

References

1. Biosimilars can significantly reduce employer pharmacy costs. Are you missing out? Kaiser Permanente. October 24, 2023. Accessed October 10, 2024. https://business.kaiserpermanente.org/california/healthy-employees/pharmacy/biosimilar-reduce-costs

2. AMA survey indicates prior authorization wreaks havoc on patient care. AMA. Press release. June 18, 2024. Accessed October 10, 2024. https://www.ama-assn.org/press-center/press-releases/ama-survey-indicates-prior-authorization-wreaks-havoc-patient-care