Prior authorization (PA) is used by health insurance providers to ensure patients access to safe, effective, affordable, high-quality care while avoiding unnecessary costs. The downside is that it can be administratively burdensome to every stakeholder across the health care continuum of care. Manual PA often results in faxing and phone calls between providers and health insurance providers, care providers, and pharmacies. Where this impacts pharmacies the most is when a patient arrives at the counter to fill a prescription only to learn a prior authorization is required prompting the pharmacist to call the provider and determine if an alternate therapy can be prescribed or to determine what next steps the patient needs to take. Automating prior authorization may help improve this process.
Increasing the adoption of electronic prior authorizations (ePAs) was one of the five major opportunities identified for improving the prior authorization (PA) process in a 2018 Consensus Statement between care providers and health insurance providers. This agreement resulted in America’s Health Insurance Plans (AHIP), along with several member insurance providers, launching the Fast Prior Authorization Technology Highway (Fast PATH) initiative with the goal of understanding the impact of ePA on the overall PA process. This novel initiative and evaluation lay the foundation for more research on strategies for further improving electronic prior authorization.
Denise H. Clayton, PhD
Senior Health Economist
Dr. Denise Clayton is a senior health economist at RTI International where she leads health economics and evaluation work. Her research focuses on evaluating digital health tools, innovative healthcare delivery models, health policy, and insurance benefits with a specific focus on the effects on health, expenditures, and utilization. Her research often focuses on underserved populations, mental health and social determinants of health.
Prior to joining RTI, she worked for AVOS Life Sciences, a boutique management consulting firm focused on strategy for the pharmaceutical industry.
She is a member of the American Economic Association, American Society of Health Economists and International Health Economics Association. She has a PhD in economics from the University of California at San Diego where she also taught several seminars and courses on applied microeconomics and health economics.
Regional Vice President, Health Plans
Tim Capstick has held numerous roles focused on assisting health insurance providers, employers, providers, and consumers of healthcare to lower pharmacy costs while improving health outcomes. Currently, he is a Regional Vice President for health insurance providers at Surescripts.
Manager, Product Innovation
Kelly Bundy is a Manager of Product Innovation at Surescripts overseeing the Electronic Prior Authorization solution which provides communication and connectivity between clinicians at health systems and clinics and the pharmacy benefit managers and health plans. Kelly has been with Surescripts for 7 ½ years focusing on clinical interoperability solutions as well as electronic prior authorization solutions.