Healthcare Technology Featured Article

November 03, 2017

Automating Enrollment for Specialty Prescriptions

Millions of patients require expensive specialty medications. Before they can get these prescriptions filled, they must go through today’s complex paper-phone-fax processes for enrollment using a specialty pharmacy or “hub” associated with the drug’s manufacturer. Recognizing there must be a better way, the industry is taking steps to automate this process. These efforts build on standards and implementations for electronic prescribing (ePrescribing) as well as complement the work under way to automate other aspects of specialty pharmacy. 

Enrollment today. Enrollment today for a specialty medication is a complex, manual process. Specialty pharmacies and hubs gather patient-specific demographic, clinical and other data to support the necessary close supervision and monitoring of the patient; the special handling of the drug that is often required; and various administrative processes, such as eligibility and payment. This primarily is done manually with paper forms, which lack consistency and standardization in the data elements required by either the specialty pharmacy or manufacturer. Information is gathered and shared by phone and fax. This creates time-consuming, frustrating, expensive, uncompensated work for a provider. Automating the process is expected to eliminate such issues as well as integrate enrollment into the electronic workflow of providers and pharmacies.

Currently, there are some business-to-business solutions that are filling this gap in lieu of having standards. Such proprietary solutions are valuable in the short term but, candidly, can be difficult to scale. They can also make it difficult for specialty pharmacies to be interoperable with the standards-based infrastructure used for ePrescribing.  

Opportunities. While automating the specialty prescribing enrollment process is complicated, there are opportunities to accelerate the process. Many are already under way, including:

  • Eliminating standards gaps. Stakeholders are coming together to identify additional or enhanced standards to support enrollment and other aspects of specialty pharmacy automation. Two standards development organizations are very active: Health Level 7 (HL7) and the National Council for Prescription Drug Programs (NCPDP). 

HL7’s FHIR (Fast Healthcare Interoperability Resources) is likely to become the standard of choice to extract relevant patient administrative and clinical data from electronic health records. NCPDP is addressing the transition to electronic specialty prescribing through its Specialty Electronic Prescribing Task Group. It is looking into ways in which new data elements useful in the enrollment process can be incorporated in the SCRIPT standard. These include, for example, additional patient contact and demographic information, diagnosis, lab values, height and weight.                

  • Building on ePrescribing. Now that ePrescribing is the norm for most other medications, it increasingly is being viewed as a solution to reduce the costs and administrative burdens associated with specialty prescribing. Two ePrescribing transactions are particularly well suited to the requirements of specialty prescribing.

  1. Electronic prior authorization. Through use of the electronic prior authorization standard (ePA) in NCPDP SCRIPT, prospective PA has been automated for ePrescribing and is being adopted nationwide. It can help facilitate PAs that are needed for many specialty medications and get them approved more quickly. This reduces speed to therapy and expensive overhead for pharmacies and physician practices. Use of ePA for specialty medications also is expected to reduce extensive outlays by pharmaceutical companies for administrative assistance for prescribers and patients.
  2. Real-time benefit inquiry. There currently is no clear way for pharmacies and hubs to identify plans as well as formulary and benefits associated with individual patients. In addition, specialty drugs are often split across medical and pharmacy benefit plans, making it difficult and time consuming to figure out who pays. While benefit verification is being done retrospectively, an NCPDP Task Group is working to identify options to support a real-time benefit inquiry (RTBI). RTBI’s value lies in its potential for providing real-time, patient-specific formulary and benefit information at the point of prescribing or enrollment. This includes patient-specific condition management programs (such as PA and step therapy), true out-of-pocket costs for a medication (specific co-pay/coinsurance amount) and specific deductible information. 

  • Demonstration projects. The ability of the industry to sponsor demonstration projects will yield realistic understanding of potential use cases and needed standards; priorities for tackling challenges; and creation of support from organizations to drive collaborative standards efforts. There is a need to move the ball down the field by helping stakeholders better understand the value of automating specialty pharmacy transactions.

Th industry is making progress toward automating specialty prescribing but by focusing on these specific opportunities, stakeholders can significantly accelerate the process.  

photo courtesy of BigStock

Edited by Mandi Nowitz
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