UNASSIGNED: Obtaining prior authorization (PA) before treatment is becoming increasingly burdensome in oncology, especially in radiation oncology. Here, we describe the impact of a strategic novel operational PA redesign to shorten authorization time and to improve patient access to cancer care at a large United States academic proton therapy center. We ask whether such a redesign may be replicable and adoptable across oncology centers.
UNASSIGNED: Our PA redesign strategy was based on a 3-tiered approach. Specifically, we (1) held payors accountable to legally backed timelines, (2) leveraged expertise on insurance policies and practices, and (3) updated the submission, appeal writing, and planning procedures for PA. Metrics were compared at the following 3 time points: 6 months before, at phase-in, and at 6 months after intervention.
UNASSIGNED: In analyzing the impact of improving PA access to care, the percentage of approvals for commercial proton beam therapy improved by an absolute 30.6% postintervention (P < .001). The proportion of commercially insured patients treated with proton beam therapy also increased by 6.2%, and the number of new starts rose by 11.7 patients/mo. Overall patient census increased by 13 patients/d. Median authorization time was 1 week, and 90% of surveyed providers reported reduced PA burden and improved patient care.
UNASSIGNED: This is the first validated, comprehensive operational strategy to improve access to cancer therapy while reducing the burden of PA. This novel approach may be helpful for addressing barriers to PA in medical and surgical oncology because the redesign is predicated on laws that regulate PA across disciplines.

BACKGROUND: Policy is a powerful tool for systematically altering healthcare access and quality, but the research to policy gap impedes translating evidence-based practices into public policy and limits widespread improvements in service and population health outcomes. The US opioid epidemic disproportionately impacts Medicaid members who rely on publicly funded benefits to access evidence-based treatment including medications for opioid use disorder (MOUD). A myriad of misaligned policies and evidence-use behaviors by policymakers across federal agencies, state Medicaid agencies, and managed care organizations limit coverage of and access to MOUD for Medicaid members. Dissemination strategies that improve policymakers\' use of current evidence are critical to improving MOUD benefits and reducing health disparities. However, no research describes key determinants of Medicaid policymakers\' evidence use behaviors or preferences, and few studies have examined data-driven approaches to developing dissemination strategies to enhance evidence-informed policymaking. This study aims to identify determinants and intermediaries that influence policymakers\' evidence use behaviors, then develop and test data-driven tailored dissemination strategies that promote MOUD coverage in benefit arrays.
METHODS: Guided by the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework, we will conduct a national survey of state Medicaid agency and managed care organization policymakers to identify determinants and intermediaries that influence how they seek, receive, and use research in their decision-making processes. We will use latent class methods to empirically identify subgroups of agencies with distinct evidence use behaviors. A 10-step dissemination strategy development and specification process will be used to tailor strategies to significant predictors identified for each latent class. Tailored dissemination strategies will be deployed to each class of policymakers and assessed for their acceptability, appropriateness, and feasibility for delivering evidence about MOUD benefit design.
CONCLUSIONS: This study will illuminate key determinants and intermediaries that influence policymakers\' evidence use behaviors when designing benefits for MOUD. This study will produce a critically needed set of data-driven, tailored policy dissemination strategies. Study results will inform a subsequent multi-site trial measuring the effectiveness of tailored dissemination strategies on MOUD benefit design and implementation. Lessons from dissemination strategy development will inform future research about policymakers\' evidence use preferences and offer a replicable process for tailoring dissemination strategies.

Prior authorizations (PAs) are commonly used by health payers as cost-containment strategies for expensive medications, including infused biologics. There is scarce data about the effect of PA requirements on patient-oriented outcomes.
We included patients for whom an infusible medication was prescribed for a rheumatologic condition. The exposures of interest were a PA requirement and whether or not the PA was denied. The primary outcome was the difference in days from medication request to infusion. Secondary outcomes included the proportion of denied PAs and differences in glucocorticoid exposure following a PA request.
Of the 225 patients, the infusible medications of 160 (71%) required a PA. PAs were associated with a greater number of days to infusion compared to cases in which no authorization was required (median 31 days [interquartile range (IQR) 15-60 days] versus median 27 days [IQR 13-41 days]; P = 0.045), especially among the 33 patients (21%) whose PA was denied initially (median 50 days [IQR 31-76 days] versus median 27 days [IQR 13-41 days]; P < 0.001). PA denials were associated with greater prednisone-equivalent glucocorticoid exposure in the 3 months following the request than when a PA was not required (median 605 mg [IQR 0-1,575] versus median 160 mg [IQR 0-675]; P = 0.01). Twenty-seven of the 33 PA requests that were initially denied (82%) were eventually approved. Thus, 96% of all PAs were ultimately approved.
PA requirements are associated with treatment delays and denials are associated with greater glucocorticoid exposure. Because the great majority of PA requests are ultimately approved, the value of PA requirements and their impact on patient safety should be reevaluated.

OBJECTIVE: The barriers and solutions to the current prior-authorization (PA) process at an integrated health system were evaluated.
METHODS: Focus groups were conducted with patients at an integrated health system who also had insurance from an affiliated health plan and at least 1 denial for a medication in the past year. Semistructured interviews were conducted with medical staff (physicians, office staff, and PA experts). Both focus groups and interviews were audio-recorded and transcribed. Inductive analysis was used to code transcripts and develop themes.
RESULTS: Three focus groups were conducted with 13 patients, and 9 medical staff (3 staff physicians, 2 office staff, and 4 PA staff) who have interactions with the PA process interviewed. Several themes were identified including the complexity of the PA process, consequences experienced, and ineffective communication between key stakeholders. A cross-cutting theme was that stakeholders expressed feelings of frustration, anxiety, and anger throughout the PA process. All stakeholders offered insights on how the process could be improved to better facilitate their preferences, such as access to the list of medications that require PA and the need for a patient advocate.
CONCLUSIONS: Results of this study revealed that the PA process was frustrating, upsetting, and infuriating to patients and medical staff involved in the process. Three main themes identified included the complexity of the PA process, consequences experienced from the PA process, and ineffective communication between stakeholders.

The prior authorization (PA) process for medications used by community providers requires modernization. Therefore, a deeper understanding of current state of PA from the community provider perspective is imperative to inform and modernize this managed care tool.
Objectives of this study were to identify, analyze and categorize the issues associated with the medication PA process from provider practice perspective.
A prospective non-experimental, cross sectional, observational study was performed using semi-structured interviews and direct observation at a convenience sample of eight primary care and medicine subspecialty group practices in Tucson, Arizona, USA. Participating practices were required to have an established medication PA process. The participant feedback from each site was analyzed using the Richards qualitative coding technique that includes descriptive coding, topic coding, and analytical coding.
Data were obtained from eight unique community provider offices (8 sites) at which 29 prescribers practice. The pain points identified represented five main categories: 1) information transfer gaps; 2) format disparities; 3) outdated technologies; 4) care consequences; and 5) workarounds. Prescribers and their staff suggested improvements that included real time eligibility and formulary alerts regarding PA during the e-prescribing process, accurate, up-to-date formulary data with easy-to-access alternatives, and embedded PA that is integrated with electronic medical record data. Three sites used medication PA portals such as CoverMyMeds® for information gathering, but at the time of data collection, no sites used these PA portals for prospective electronic prior authorization (ePA) or the electronic process of requesting authorization from health plan payers for coverage.
The PA process for medication used by community providers is in urgent need of modernization. Pain points identified in this study could be alleviated by implementing medication ePA solutions. However, providers and their staff are largely unaware that ePA exists. Additional research in this area is needed.

暂无摘要。

To quantify and explain variation in use of long-acting injectable antipsychotics (LAIs) in the United States, and understand the relationship between patient characteristics, drug reimbursement policies, and LAI prescribing after relapse.
A cohort of recently relapsed patients with schizophrenia ages 18 to 64, were identified immediately after discharge from a related inpatient hospitalization, partial hospitalization, or emergency room visit, drawn from 2004 to 2006 Medicaid claims, and followed for 90 days until LAI initiation. Data on state-level Medicaid prior authorization (PA) policies for LAIs were collected. Sequential longitudinal Poisson regression models were developed to understand the relationship between patient and PA policy variables and LAI prescribing, including prior adherence to oral antipsychotics, demographics, clinical variables, and presence of PA policy for LAI.
Among 36 282 patients, 3.1% received risperidone LAI, and 3.8% received a first-generation (FGA) LAI with wide variation across states. Prior adherence ranged from 29% to 89% but was marginally associated with initiation and did not explain variation for LAI prescribing. FGA initiation was associated with geography and race/ethnicity but not PA policy. For risperidone LAI initiation, demographics and clinical factors explained, respectively, 5.0% and 3.0% of the variation; PA policy had a large negative association with initiation (RR = 0.41; 95%CI 0.20-0.87) and explained 8.4% of the variation.
PA policies may represent a major treatment barrier for risperidone LAI among relapsed patients. Non-adherence plays a little role in predicting which patients receive LAIs. Policy makers and health insurers will need to consider these findings when guiding the use of LAIs. KEY POINTS Among a nationwide cohort of relapsed schizophrenia patients enrolled in US Medicaid, 3.1% received Risperdal Consta, a long-acting injectable antipsychotic (LAI), and 3.8% initiated a first-generation first-generation LAI within 90 days after discharge. During 2004 to 2006, there was marked variation in 90 day post-relapse initiation of Risperdal-Consta-a newly marketed medication during this period-and also marked variation in 90 day post-relapse initiation of any first-generation LAI, which appeared to be associated with race/ethnicity and geography. Prior authorization policies were associated with substantially lower initiation of Risperdal Consta in this cohort of relapsed patients even after accounting for clinical indication (non-adherence), relapse history, demographics, adjunctive medication, and mental health service use.

U.S. State Medicaid programs for the medically indigent strive to deliver quality health care services with limited budgets. An often used cost management strategy is prior authorization of services or prescription medications. The goal of this strategy is to shape the pharmaceutical market share in the most efficient manner for the particular state Medicaid program, much like commercial managed care organizations. These policies are often scrutinized due to the population Medicaid serves, which in the past was largely composed of individuals with vulnerable health status. Unintended consequences can occur if these policies are not carried out in an appropriate manner or if they greatly restrict services. The data used for policy implementation research is prone to certain problems such as skewness and multimodality. Previous guidelines have been published regarding the best practices when analyzing these data. These guidelines were used to review the current body of literature regarding prior authorization in Medicaid. Further discussed are additional characteristics such as therapeutic areas researched and the outcomes identified. Finally, the importance of considering state-specific characteristics when reviewing individual policies and the usefulness of these results for other programs are also considered.

BACKGROUND: Many hospitals have implemented antimicrobial stewardship programs (ASPs) and have included in their programs strategies such as prior authorization and audit and feedback. However there are few data concerning the facilitators and barriers that ASPs face when implementing their strategies. We conducted a qualitative study to discern factors that lead to successful uptake of ASP strategies.
METHODS: Semistructured telephone interviews were conducted from June-July 2013 with 15 ASP member pharmacists and 6 physicians representing 21 unique academic medical centers.
RESULTS: Successful implementation of ASP strategies was found to be related to communication style, types of relationships formed between the ASP and non-ASP personnel, and conflict management. Success was also influenced by the availability of resources in the form of adequate personnel, health information technology personnel and infrastructure, and the ability to generate and analyze ASP-specific data. Types of effective strategies commonly cited included audit and feedback; prior authorization, especially with an educative component; and use of real-time alert technology and guidelines.
CONCLUSIONS: Several factors may influence ASP success in the implementation of their strategies. ASP members may use these findings to improve upon the success of their programs.