Leveraging ambulatory care pharmacist expertise in medication appeals to overcome access barriers: A descriptive report

Abstract

Introduction Prescription prior authorization (PA) and prohibitive out‐of‐pocket costs are encountered across all specialties of care. These barriers are burdensome for prescribers and patients due to the multiple steps required to gain approval for payer reimbursement for medications. Objectives The primary objective was to characterize clinical pharmacist impact on medication appeals and high cost resolution. Methods This was a retrospective review of medication access intervention data collected from January 1, 2021, through July 31, 2021, at an academic medical center where five clinical pharmacists are embedded across 11 specialty and family medicine clinics. Intervention data was documented for both specialty and nonspecialty prescriptions. The primary end point quantified and characterized interventions based on access issues, defined as insurance denial or high out‐of‐pocket cost. Additional end points included time to appeal determination, total time spent on appeal activities, the incidence of denials, duration of the interruption, and assistance dollars secured for cost‐related barriers. Results Over the 7‐mo period, there were 531 prescriptions identified for clinical pharmacist access intervention. Of the total interventions collected, 42% (n = 221) were appeals for insurance denials and 58% (n = 310) addressed high out‐of‐pocket cost. The approval rate of appeals was 94% (n = 208). The majority of appeals (89%) were submitted within 3 d. The median time to appeal determination was five calendar days. The estimated time spent on appeal activities by the clinical pharmacists was 6.8 work wk. There were 51 patients of therapy interruption. The total assistance dollars secured for high out‐of‐pocket costs reached an estimated $1 953 200 over the report period.ConclusionThis report characterizes an approach to effectively manage medication appeals and cost resolution through embedded clinical pharmacists. Leveraging embedded pharmacists' clinical knowledge and familiarity with payer processes in medication appeals achieved a 94% approval rate. The current payer process places a burden disproportionately on prescribers and patients, delaying or preventing medication access.

Management and Outcomes of Patients at a Specialty Clinic for Clostridioides difficile Infection

“…During their clinical course, patients with rCDI commonly require multiple or repeated therapies to achieve sustained clinical cure [ 5 ]. Thus, expert management could aid in addressing issues of recurrence and improve clinical outcomes [ 9 , 10 ].…”