Decoding Prescriber Intent: Maximizing Patient Access and Specialty Pharmacy Efficiency Through Prior Authorization Optimization

PCSK9 inhibitors are medications that help to lower cholesterol by decreasing low-density lipoprotein (LDL, or “bad”) cholesterol levels in the blood, thereby lessening the risk of cardiovascular problems.¹ They help to block the PCSK9 protein, which leaves more receptors in the liver available to clear the LDL cholesterol.²

Steve Davis and Kodi Reel, PharmD, Forsyth Health

Using this class of medications as a case study, Kodi Reel, PharmD, senior vice president of product growth and manufacturing, and Steve Davis, chief product growth officer, both from Forsyth Health—a health care and data analytics company that uses real-time pharmacy data and advanced processes to help guide clients to their optimal product development and market access decisions³—presented, “Prescriber Intent: The Key You’ve Been Missing,”⁴ on day 1 of AXS24, the 20th Asembia summit.

They chose to focus on the PCSK9 market because it is an established market that has a lot of governance and clinical and behavioral criteria that have to be satisfied for something to get approved via the prior authorization (PA) process.

Just as it is important for retail analysts to help businesses and their owners to understand their customers’ decision-making processes to better meet their future needs and personalize their shopping experiences, so is it important for the specialty pharmacy industry to understand the actions of prescribers and how the often inefficient prior authorization process affects patient outcomes, Reel and Davis emphasized. Data on these patterns can help to inform how to optimize new product launches and identify where there is potential to increase the efficiency of prescribing processes with high-value prescribers, which in turn can facilitate patient access to medications.

Important here are intent to prescribe, influences on the decision-making process, and investment in follow-through, or working through challenges to make a decision.

“Much like retailers, prescribers take action,” Reel said. “They’ll either take a prescription and start by processing a prior authorization or they’ll send that script directly to the pharmacy, in which case it may end up in a transaction. Or it could be rejected if a PA is required, in which case it’s going back to the prescriber.”

Proactive prescribers do everything they can to help ensure access before they make promises to patients, Reel continued. In a perfect scenario, all the information required for a PA is submitted, the script is sent to the pharmacy, and the patient has their medication. A sale has gone through. But sometimes PAs get kicked back, and what prescribers do next is the information the specialty pharmacy industry could benefit from, “the key that’s been missing”: insight on how to better understand prescriber decision-making.

Deidentified data that Davis presented showed space for opportunity, he termed it.

“These data show you all the way through what you need to do to improve things,” he said.

Among 44,858 patients for whom PCSK9 prescribing attempts were made, only 68% overall went on product, either because their physician kicked off the PA process or the script went directly to the pharmacy, which initiated the PA process.

“That means there’s 32% opportunity space for us as an industry,” Davis noted. “And this rate is the same for almost every market—inflammation, oncology, neurology.”

When prescribers are proactive about PAs, the fulfillment rate is higher (76%) and the denial rate is lower (12%) compared with scenarios that involve reactive PA (59% and 27%, respectively), which occur when a physician sends a script to the pharmacy first without a PA and the pharmacy agent pushes it through or the pharmacist has to push back for more data on the patient.

What does this tell Reel and Davis? “If we could get more prescribers to take better stewardship of the prior authorization process, we would have better throughput and more patients on the brand that the physicians intended them to be on.”

They presented 3 examples to illustrate this point:

• Of 17,449 PAs for PCSK9 inhibitors that were submitted by proactive physicians that were approved on first pass, 87% of patients went on the intended product; of the 13% who did not, 40% went on another product and 60% had no prescription activity. The average turnaround time in this scenario was 1.15 days.
• Of 5323 PAs for PCSK9 inhibitors that were submitted by proactive physicians that were denied on first pass, 48% eventually were approved, and of these, 87% (or 42% overall) went on the intended product; among the 13% who did not, 71% had no follow-up prescription activity and 29% went on something else. The average turnaround time in this scenario was 45.8 days.
• Of 22,086 prescriptions for PCSK9 inhibitors for which a PA was required but the doctor bypassed the process and sent the script direct to the pharmacist, 90% had a PA submitted, of which 73% received the PA and 91% went on the intended product (or 59% overall); among the 9% who did not, 55% eventually went on another product and 45% had no follow-up prescription activity. Average turnaround time was 15.9 days.

“Each time this process has another gateway to go, another decision tree, another point of disconnection, is another opportunity for failure. That’s why it’s so important for the physicians to take ownership of this thing,” Davis highlighted. “And whenever you measure a process, you end up working to improve that process. You always want to design the most succinct process with the fewest gateways for failure.”

“There is hope in this process, but there’s a ton to be learned here, too,” Reel concurred. “You need the right data and the right tools to help you understand prescribers.”

References

1. PCSK9 inhibitors. Cleveland Clinic. Updated February 17, 2022. Accessed April 29, 2024. https://my.clevelandclinic.org/health/drugs/22550-pcsk9-inhibitors

2. Hajar R. PCSK 9 inhibitors: a short history and a new era of lipid-lowering therapy. Heart Views. 2019;20(2):74-75. doi:10.4103/HEARTVIEWS.HEARTVIEWS_59_19

3. About us. Forsyth Health. Accessed April 29, 2024. https://www.forsythhealth.com/

4. Reel K, Davis S. Prescriber intent: the key you’ve been missing. Presented at: AXS24; April 28-May 2, 2024; Las Vegas, NV. https://asembia2021.egnyte.com/fl/u6bmUePsTR#folder-link/AXS24%20Session%20Slides?p=c2bce964-0ad5-4b4a-a1a4-c6cb921df0f1