AMCP Partnership Forum: Optimizing Prior Authorization for Appropriate Medication Selection
AMCP Partnership Forum: Optimizing Prior Authorization for Appropriate Medication Selection
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DOI：
10.18553/jmcp.2020.26.1.55
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发表时间：
2020-01-01
影响因子：
2.1
通讯作者：
Rolle, Tricia Lee Wilkins
中科院分区：
文献类型：
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作者：
Bain, Amanda;Bonome, Heather;Rolle, Tricia Lee Wilkins
事先授权（PA）和阶梯疗法（ST）是管理式医疗机构使用了几十年的使用管理工具。这些流程要求医疗保健提供者在将特定产品交付给患者之前获得事先批准，以使其符合健康计划的承保范围。这些工具旨在确保患者能够获得循证药物，同时支付者仍然是有限医疗资源的良好管理者。PA和ST越来越多地用于支持药物的适当使用和管理相关成本，但可能会带来与管理负担和获得护理相关的挑战。2019年6月，管理式医疗药房学院（AMCP）举办了一个多方利益相关者论坛，以确定优化PA和ST使用管理计划的流程。代表学术界、健康计划、综合交付系统、药房福利管理人员、雇主、联邦政府机构、国家卫生保健提供者组织和患者倡导组织的卫生保健领导人参加了论坛。与会者探讨了这些方案的当前运作，评估了利益相关者对改进这些方案的机会的看法，并为下一步行动提出了建议。他们还审查了当前联邦和州的立法和监管活动，以改革PA和ST流程，并提供指导，以支持计划的改进。论坛的目标是收集利益相关者的意见，为制定提高PA和ST流程效率的建议提供信息;提供解决行政负担的建议;提高PA和ST利用管理计划的临床和经济价值的可见性;收集、审查和传播支持临床和经济价值的PA计划的数据驱动的真实世界经验;收集和传播有关PA上诉和拒绝程序的最佳做法;改善健康保险提供者、医疗保健专业人员和患者之间的沟通渠道，以最大限度地减少护理延误，提高保险授权要求的清晰度。版权所有（c）2020，管理护理药房学院。All rights reserved.
Prior authorization (PA) and step therapy (ST) are utilization management tools that have been in use by managed care organizations for decades. These processes require that health care providers obtain advanced approval to qualify a specific product for coverage from a health plan before it is delivered to the patient. These tools are intended to ensure that patients have access to evidence-based medications while payers remain good stewards of limited health care resources. PA and ST are growing in use to support appropriate use of medications and manage associated costs but may pose challenges related to administrative burden and access to care.In June 2019, the Academy of Managed Care Pharmacy (AMCP) conducted a multistakeholder forum to identify processes for optimizing PA and ST utilization management programs. Health care leaders representing academia, health plans, integrated delivery systems, pharmacy benefit managers, employers, federal government agencies, national health care provider organizations, and patient advocacy organizations participated in the forum. Participants explored current operations of these programs, evaluated stakeholder perspectives on opportunities to improve these programs, and provided recommendations for next steps. They also reviewed current federal and state legislative and regulatory activities to reform PA and ST processes and offered guidance to support program improvements.The goal of the forum was to gather stakeholder input to inform the development of recommendations to improve efficiencies around PA and ST processes; provide recommendations to address administrative burdens; increase the visibility of the clinical and economic value of PA and ST utilization management programs; collect, review, and disseminate data-driven, real-world experiences of PA programs that support clinical and economic value; collect and disseminate best practices around PA appeals and denial processes; and improve channels of communications between health insurance providers, health care professionals, and patients to minimize care delays and improve clarity of coverage authorization requirements. Copyright (c) 2020, Academy of Managed Care Pharmacy. All rights reserved.