Are prior auths blocking patients from their meds?

Medication adherence remains one of the most persistent challenges in American healthcare, with estimates putting the cost to the health system at close to $500 billion. A significant driver is the fact that roughly one in four prescriptions are never picked up after being written, often leaving physicians unaware of the problem until a patient's next visit months later. Prior authorization compounds the issue, frequently cited as a leading cause of clinician frustration and burnout, while also delaying or blocking patients from getting needed medications. New CMS proposals aim to bring regulatory pressure and standardized timelines to the prior authorization process, building on earlier efforts in the medical prior auth space. Beyond policy, adherence is shaped by financial barriers, patient understanding, and simple forgetfulness, all of which require thoughtful, personalized engagement to address. Medical Economics spoke with Colin Banas, M.D., chief medical officer, Dr.First about these issues.

Medical Economics: How big of a problem is medication adherence currently?

Colin Banas: This is a big problem. Most estimates put it at close to a $500 billion problem for the U.S. health system. At Dr.First, we're fond of quoting a statistic related to first fill not getting picked up for a medication: it's over 25%, so one in four prescriptions that I write as a physician won't get picked up by my patient, and I might not ever figure that out until the patient comes to see me again, which could be six to 12 months later. What happens is I've lost a lot of time and potential momentum in a lot of these chronic diseases, and the downstream effect is poor clinical outcomes, readmissions to the hospital you name it. As an internal medicine physician, one of my biggest tools is prescription medications, and if I can't get and keep my patient on therapy, then I'm doing a disservice to my patient and to the health system at large.

Medical Economics: Prior authorizations are often a problem for both physicians and patients. For those who aren't familiar, can you describe what CMS has proposed regarding prior authorization for prescription drugs?

Colin Banas: CMS is finally putting their foot down, if you will, to help move along the prior auth problem, and they're doing it through regulatory pressure and standards. Prior authorization is cited as probably the number one cause of frustration and burnout among the clinician group. About a year ago, a variety of payers made a pledge to help improve this prior authorization problem, and it was kind of like a pinky swear. I was very skeptical at the time, and I still remain skeptical, but a year later, CMS got a lot of the stakeholders together and said what can't be solved with pinky swears and promises, maybe we can solve with a little regulatory pressure. Just like they did two years ago to define a standards pathway for medical prior authorization, think of needing permission for an MRI or for a particular surgery or procedure, they have now done the same thing for prescription prior authorization. They've set out standards and a timeline.

Medical Economics: Does the policy go far enough? Do you think it will actually make a difference?

Colin Banas: I do think it'll make a difference. We've seen similar comments and proposed rules around interoperability and standards in the electronic health record space move the needle. For a lot of us, the needle doesn't move fast enough. I've been in medicine for almost 25 years, informatics for 20 of them, and we're still talking about interoperability, which is a little crazy, but you have to take the wins as you can get them. It's certainly a lot better than it was 10 years ago. I'm not going to doom and gloom this, but on the same hand, we still have fax machines and reams of paper that we're dealing with. When the carrot doesn't necessarily work fast enough, then you start to use the stick, and that's what these regulations are ostensibly doing.

One of the problems is that CMS only has so many levers they can pull, meaning they can only truly regulate or influence the payers and patients that they are responsible for, think Medicare, Medicaid, CHIP. The private sector doesn't necessarily have to move along, though they typically do, because a lot of those big players operate in both spaces. In addition to this regulatory pressure, I think we're also seeing increased focus on this due to frustration from providers and patients. Patients are finally getting so fed up that they are voicing their frustration, and a lot of this gets amplified by social media and by poor outcomes that make the news cycle, a child who couldn't get their inhaler, gets admitted to the hospital and eventually passes away. A lot of people will tie that back to how obfuscated this whole process is, how limited insight we have into the rules of prior authorization and approval.

I'm fond of saying that doctors, and by proxy, patients, are being asked to play a game without necessarily knowing the rules to that game. Imagine all you needed to do was get the ball into the basket. The ball is the medication, the basket is the patient. Seems simple enough, but oh, you took too many steps, oh, you didn't cross half court in time, go back to the baseline, the shot clock ran out. I didn't know there were rules, I just thought I had to get the ball in the basket. What you really need is to couple policy with thoughtful decision support as guidance to patients and providers, to help them understand how to play the game.

Medical Economics: What else needs to be done to make sure patients are adhering to their medications? It's not just a policy issue, is it?

Colin Banas: No, gosh, no. Nonadherence is multifactorial. I like to say there are kind of three buckets as to why patients don't pick up their medications. The first bucket is financial, sticker shock upon arrival at the pharmacy, or not enough financial resources to fill all of your medications, so you start picking and choosing or splitting doses, which is technically nonadherence. Anything we can do to shed light on affordability for those medications, both at the provider and patient level, is critical. Things like, at the moment of prescribing, does your system have the price benefit turned on so you can see what the copay for that patient is going to be? If the copay is above $100, which is kind of the magic tipping point in the literature, you can have a conversation with the patient about whether they're going to be able to afford it, or whether you need to find alternatives or guide them to other resources like copay assistance or hub services. Dr.First is very proud of the fact that we put a lot of that financial data front and center, not only for the provider but also for the patient, to help empower them to go get these medications.

The second bucket is understanding or education. Patients sometimes don't really understand how important a medication is, what the potential side effects are, or why they can't skip days or split doses. How can we educate them, letting them know the first week might be a little rough, but after that it's all going to be better, those side effects, that nausea, are going to go away? Because if they don't know that, and they take it for three days and feel terrible, they might abandon it altogether, and I might not find that out for a year until they come back, and now I've lost that progress.

The last bucket is that life gets in the way. People forget. The thing is sitting out at the local pharmacy, they didn't get it, and two weeks later it goes back on the shelf. One of our solutions has ways to do thoughtful nudges, don't forget to go get your medication, here are some price support options, here's some education regarding that medication, and this is all personalized and delivered via SMS. What I'm really getting at is that one of the key things for adherence is patient engagement, particularly personalized patient engagement. Different patients fall into different buckets, and in this age of big data and artificial intelligence, how can we make sure we're personalized to the individual patient to get the optimal outcome, which is getting patients on and keeping them on therapy?

Medical Economics: With all the promises of technology in addressing the prior auth issue, do you think we'll ever get to the point where it's instantaneous, where the doctor puts in the drug and it immediately flags whether that's an allowed medicine? Do you think we'll get there?

Colin Banas: We're going to get close. One of the things in this rule is that it's setting timelines for response rates, meaning for prescriptions that require a prior auth, you are required to provide an answer within 24 hours, not a week, not two weeks later. But I think we can be a lot more thoughtful in guiding the prescriber to provide the requisite information up front to avoid the prior auth in the first place. We have our own data showing that for particular drugs, you can actually avoid prior authorization simply by attaching the appropriate ICD-10 code. If I knew that, I would attach that code every time, because I don't want to get the phone call or the fax later. That's the nod to the assistance we can provide during prescribing. I do think this is largely solvable by technology, but I still think there will be edge cases where you're going to have peer-to-peer conversations for really complex situations that don't lend themselves to deterministic outcomes. There really is still an art to medicine, it can't all be point and click. I'm fond of saying that the best decision support is like the lanes on a highway. I know I need to keep my car between those lanes to arrive at my destination safely, but I still have agency. I'm still the doctor. If I need to do something different because it's the right thing to do, those lines don't stop me, I can deviate to go do the right thing. That's the art of medicine that really can't be replaced by technology, although a lot of people think it can.

Medical Economics: You mentioned a lot of different types of barriers to patient adherence. Are there simple things doctors could do today to help their patients adhere to their medications more than they are?

Colin Banas: I think being very transparent is key. The process, as I said earlier, is currently very non-transparent for both parties. A lot of times the patient assumes that I know what they can afford, or what's going to be covered, or what's going to require a prior authorization, and a lot of times we're flying just as blind as the patient until we get the phone call or the fax a day or two later. This is where technology and companies like Dr.First and other patient engagement solutions can really help. So transparency, education, and openness to have these conversations, because sometimes they're difficult conversations to have with patients, particularly around affordability. A lot of patients might be too proud to bring up that they're never going to go get a prescription because there's no way they can afford it, it's that or groceries. It's about removing the stigma, because a lot of times there are alternatives, we can get creative and find different care pathways or connect with resources. It really is about a very open and honest two-way street between provider and patient.