An Interview with Surescripts’ David Yakimischak

David Yakimischak is an executive vice president and general manager for Surescripts’ medication network services. In that role, he is responsible for the e-prescribing business, as well as all of the additional value-added services that are built around that. In this interview with ComputerTalk’s Will Lockwood he talks about a new area that Surescripts is now entering: facilitating electronic prior authorizations. Yakimischak outlines just what the challenges typically are with prior authorizations, where we are with standardizing and digitizing the process, and how pharmacy will see benefits from this new way to leverage the network that’s been built for e-prescribing.

ComputerTalk: What has led Surescripts to be a provider of electronic prior authorization (ePA) services?

It’s the market demand. We hear it as the number one pain point among prescribers, in pharmacies, and PBMs [pharmacy benefit managers]. It’s just the inefficiency of the process. To handle prior authorizations today is a very manual and labor-intensive process.

CT: What ePA services is Surescripts offering?

We have implemented the NCPDP [National Council for Prescription Drug Programs] standard for ePA for use over our network. This is a standard that was developed through industry debate and discussion. When it was finalized almost a year ago now, we began the process of implementing it on our network. Our initial efforts have been around connecting PBMs and EMR [electronic medical record] vendors.

CT: What does moving the prior authorization (PA) process to digital mean?

It digitizes the set of questions and answers that go back and forth between the PBM and the physician when a prior authorization is required. Prior to ePAs that would typically happen by fax, phone, or by using forms that are on custom portals. For each PA [prior authorization], there’s a specific set of questions about the patient, their medical situation, and the use of the drug. The medical practice has to fill this out, submit it to the PBM, and then sometimes there’s back and forth, maybe an appeal, maybe further questions and so on. That’s a mechanical, labor-intensive process that we can now digitize.

To make a very basic comparison, it’s like the difference between when you used to send out a paper survey, but now you can use SurveyMonkey or something similar and you have a Web-based form to fill out and digitized content to analyze as the output. It’s a lot easier and faster to get responses and to move the process along. In a simple way, that’s the difference between the paper prior authorization process and the ePA process. There’s more to it, of course, but that’s the basic concept.

CT: Who are the key players in ePA right now and what are the key elements of it? You mentioned you were beginning with EMR vendors and payers.

You’re touching on something that’s really important here, which is that what we’re doing first is digitizing the current process. The current process generally goes something like this: The prescription goes to the pharmacy, and they don’t find out that a prior authorization is required until they actually run a claim. When they do, it comes back rejected with the prior authorization code that’s required.  

So the pharmacy is now stuck. They have a prescription, but they can’t dispense it yet. The pharmacy now has to go back and contact the prescriber, and then the medical practice has to initiate the questions and answers and get the approval for the PA. The first thing that we’re digitizing are the questions and answers between prescriber and payer, and that’s the only part that the NCPDP standard has defined so far.

We can call this retrospective PA — “retrospective” meaning that the authorization is requested only after the fact of prescribing and adjudication.

The next step is going to be working out how the pharmacy will initiate the need for prior authorization by contacting the practice electronically or maybe contacting the PBM electronically. That has not been resolved yet, but we’re involved in that discussion and as that debate takes place, and as that decision gets made, we will be implementing that pharmacy connection into the network as well. But it’s not squared away exactly who’s going to initiate, how and when, and with whom.

CT: Logically then, there’s also the goal of getting a prescription authorized even before it gets to the pharmacy, right?

Yes, that’s another whole piece here that we’re working toward; that’s what we’ll call prospective PA. What that means is that, if we can get the benefit information to the doctor at the time the prescription’s being written and they know that a prior authorization is required, then they can actually kick off the process of getting that prior authorization filled out and approved, before the prescription is even sent to the pharmacy.

So once the prescription gets to the pharmacy, they’ll be able to adjudicate the claim and dispense the prescription like any other; there will be no friction in the system. The prior authorization will have already been dealt with prospectively by the physician, because they knew that it was needed based on the benefit information available to them.

CT: How close are we to prospective PA?

Today, the formulary information that they have only indicates that a prior authorization is likely required. Prospective prior authorization really won’t be one-hundred percent reliable until we get into more of a real-time benefit update at the point of prescribing.
But we can start with the ePA standard we have and what will work today. Then we’ll add on the piece for pharmacy to initiate, and then we’ll add on and improve the prospective piece so that hopefully — and this is the vision — we will get to a point where there’s never a prior authorization required at the pharmacy. Only approved prescriptions will ever reach the pharmacy. That’s the long-term goal here, to never have a pharmacy hit a prior authorization bump ever again.

CT: Many pharmacies see themselves as adding value for prescribers and patients by actively managing the prior authorization process now, don’t they?

That’s right, and we heard that loud and clear from pharmacy, from both independents and chains, from everybody. Pharmacy needs to be involved in the decision and the process of initiating prior authorizations because many times they’ll take care of, let’s say, getting a changed prescription before the PA is handled . Or they’ll have a suggestion, maybe they’ll contact the doctor and say, “Hey, can we talk about the situation for this patient? Maybe there’s a better lower cost alternative, that doesn’t require a PA.” And a prescriber may say, “I’ll just send a new prescription, and I’ll cancel the first one. Let’s not even bother going down the road with that prescription that requires a PA.”

CT: As long as the process is retrospective, pharmacy will retain a role there, I suppose.

Yes, and right now it’s enough work to just get the PBM-to-EMR connection working, and that will automate a lot of the process and take out a lot of cost. I think we’re on the right path, because the take-up rate with both PBMs and EMRs to do what we’ve introduced has been tremendous.

They’re literally lining up to get on board to do this because they’re getting so much demand, especially from the medical practices where, if they’ve got any number of practitioners, they’re handling dozens of prior authorizations a day. The current is complex and prior authorization management is just a literal nightmare. So anything we can do to bring automation to that, to reduce the amount of time and effort that the practice has to put in, it’s getting great acceptance. So that’s why we went out with version one the way we did. There will be more to come. This is not where it ends. This is just where it begins.

CT: Surescripts is an organization that has pharmacy at its core, within its structure, within its foundation. From a pharmacy’s perspective, where is the balance of the benefit going to accrue in this ePA process, and how is that going to evolve?

I think it accrues differently, but all the different parties will get some benefit from it. It’s not that everybody gets the same benefit. I mean think of it. The medical practice gets improvement in efficiency. The PBM gets an improvement in the amount of work that they have to do, because it’s not easy for them to handle all the paperwork on these prior authorizations either. So they get increased efficiency and a faster approval. They and the pharmacies both are going to get a higher adherence rate because we know that when there’s a prior authorization involved, that there’s a much higher abandonment rate of a prescription than there is with a prescription that doesn’t have prior authorization.

So if you can smooth out the process and get more prior authorizations handled and approved, you’re going to get less abandonment. In other words, there will be more dispensing, more prescriptions, less friction, and less hassle. So the economic benefit is pretty well spread across the board in the area of efficiency, but different stakeholders are getting different, specific benefits from the ePA process itself.


CT: What is it then that you want pharmacies to know about Surescripts and ePAs going forward?

I kind of think the big story here is that pharmacies made a big investment in e-prescribing and it’s the single most successful health IT networking example that we have in this country. So pharmacies should be very proud of what they’ve accomplished through e-prescribing. I would say that what we’re doing with ePAs is an example of leveraging that investment and expanding a little bit beyond that core of just moving the prescription.

And real credit is due to pharmacy, because as a result of the investment that everybody’s made, adding prior authorization is not a big leap. If you were just sitting down and there was no e-prescribing network and it hadn’t really caught on, doing ePA would be a big lift. We already have the connections to the EMR vendors. We have contracts with them. We have business relationship with them. We have technical connectivity. We publish guides and standards. We have a customer support department that can handle problems if they come up. We’ve got a data quality department. We’ve got a data warehouse that can look and make sure everything’s running properly. You go on and on and on down the list, and all this was built for e-prescribing, but works for ramping up ePA as well.

I would say the number-one thing I’d want pharmacy to know is that they’re still at the table — in the driver’s seat, in fact — because pharmacy is a owner of the network that is going to do this for the whole country. That’s a huge thing, and I don’t know if pharmacies necessarily understand the impact that they’ve had.

And we can leverage this network further for pharmacy — whether that’s getting into additional billable services such as MTM or immunizations or getting involved in a health information exchange. As pharmacy is becoming more a part of the care providing network, the investments that they’ve made in these early systems will bring additional advantages. They will be able to do more and participate in these new models at a lower incremental cost and with less effort.

So that’s the big picture. But then there’s the direct benefit, which is that pharmacies are going to simply get more prescriptions dispensed because of ePA. That’s something I think they need to know as well.

CT: So you reduce a significant point of friction such as prior authorization and you are going to see improvements across the board in pharmacy operations and in patient outcomes.

Right. And this is only getting to be more and more important. Consider specialty medications: Almost every one of them requires some form of prior authorization. If pharmacies are going to dispense those medications — and those are high-performance, high-revenue, sophisticated medications where prior authorizations are essentially mandatory — then they are going to see a lot of benefit from ePAs. CT