Dr Ryan Haumschild Discusses Payer, Provider Perspectives on Prior Authorization in Rare Diseases


Ryan Haumschild, PharmD, MS, MBA, director of pharmacy at Emory Winship Cancer Institute, shares his unique perspectives as both a provider and payer on the use of prior authorizations (PAs) and "Gold Cards" in patients with rare diseases.

Efficient prior authorization and measures such as "gold carding" for providers can help patients with rare diseases, not just from a cost perspective, but also in terms of quality of life, says Ryan Haumschild, PharmD, MS, MBA, director of pharmacy at Emory Winship Cancer Institute.


What technologies or strategies should be implemented to improve the timeliness of prior authorization (PA) for patients with rare diseases?

Improving the timeliness of prior authorizations, I think is such a hot topic; we could probably be here forever talking about how do we balance that? Because sometimes I bring the vision of the provider group, where we need access to these therapies right away. But I also have the managed care perspective, that we've got to be good stewards of our health care expense for employers and our benefit.

What are the strategies and tools that can be utilized for technologies? I do think that as we're evaluating prior authorizations, how do we look for patients that have rare diseases? And if a patient has a rare disease, it's a definitive ICD-10 code that's been documented, they have documentation that can be submitted, and the providers are following guideline-based therapy, we should have an expedited way to approve it.

I think about ALS [amyotrophic lateral sclerosis], for instance; we're talking about brain health. So many times, we see some of those patients don't have long to be on therapy before all of a sudden, they start declining in health. And the longer that prior authorization takes, the worse their disease becomes and progresses over time, and the worse their quality of life becomes.

How do we have more expedited medical documentation so that we can review that upfront? We provide clear expectations for the providers in terms of what they need to submit for us to review. And at the end of the day, we get access to those therapies sooner, so they can have faster time to treatment, and so they can garner even greater value from the therapy.

And I think that's really going to be the key for patients with rare diseases; clear criteria, so providers and patients know they're going to a right provider that's credentialed and privileged in that rare disease. If they're prescribing a therapy that's FDA approved and the patient has documentation, we should be able to expedite that approval, regardless of the cost, to make sure that we're getting patients access right away. And I think those are some of the things that we can look at; leveraging technology of EPAS [electronic prior authorizations] and also kind of marry together the benefit on the front end to make sure it's a more timely review.

And then lastly, we've created more timely review prior authorization cues, whether it's for PrEP [pre-exposure prophylaxis] therapy or defined vaccine management. Why don't we implement that for rare diseases as well? And even in diseases where progression can happen rapidly, so that we don't delay that patient benefit and that therapeutic efficacy that we've seen work so well in these treatments.

How does the use of PA “Gold Cards” help improve utilization management of treatment for rare diseases?

We’ve seen a lot of I would say, innovation around prior authorizations— maybe not a lot, but we're starting to see some. And I think, gold cards have been utilized in Texas and other areas, where if a provider has, let's say, a 90% or above approval rate for prior authorizations, then the following quarter, we approve all the drugs that they're requesting. And I think gold cards has got some efficacy to it; it's got some really good benefit.

I think as we're starting to evaluate the treatments, why not utilize gold carding to be pulled through in rare diseases, especially some of these specialist providers that are only treating rare diseases, where they're some of the few experts around? And I think if we look at a prior authorization approval— and maybe there's some medications we carve out of that gold card— but if we can do that, I think what it does is creates a faster time to treatment, faster time to improve the efficacy, and overall benefit from the medication or therapy. And then lastly, higher provider and patient satisfaction.

I do think gold cards are going to be something of the future, especially for patients or providers that are credentialed in rare diseases and have documentation they've already submitted. And if they're already meeting at a high approval rate, I think that should be a "go-to" answer for us for a variety of plans. And then if we have concerns, if somebody kind of crests that high drug cost build, that we can have one-off processes for those, but still review them in a timely manner.

How can providers and payers collaborate to ensure patients with rare diseases receive the best value-based care?

I like to think of myself as a provider and a payer. I like to think of myself as someone who really sees the value in both. And I do feel like we're seeing more and more collaboration, especially as we see the emergence of integrated delivery networks that have responsibility for the payer and the provider arm. But I think more and more, we are seeing value continuing to bubble up both on the payer and the provider side, because we know that the ongoing expense of health care continues to rise. And it's the responsibility of both parties to make sure that we're good stewards of health care expense.

As we're evaluating rare diseases, we need to look at the value they bring. We need to look at value not just on acquisition cost, we need to look at it from total cost of care perspective or quality of life perspective, or even looking at the ICER [Institute for Clinical and Economic Review] and the quality to say, "Does this meet the minimum threshold?" And if it doesn't, we need to have those open conversations with providers. Maybe there might be a sub-population that may benefit the most, but not all populations are going to benefit. And be very clear about that.

And even payers drawing in providers in what we call disease state working groups, where they start to engage community and academic providers when they're developing medical policy around rare disease states. What documentation should be submitted? What would be a timely approval?

As we start to sequence high-cost therapies, we've got to be mindful of total drug expense for our provider plan; which therapy should be prioritized? And then lastly, the payers can say to the provider group, if we adopt this therapy, we take on higher acquisition cost, we've got to make sure that we're reducing total cost of care, there's an offset the medical benefit. And say, here's how we see it happening, do you agree? And would this fall within the normal span of treatment? And I think the more open conversations we have there really draws out value, not just value in terms of costs, but value in terms of improving a life, quality of life, and overall reduction in total cost of care.

And I think that's really we're going to get the traction of everyone working together, and start to have more of a succinct outlook on how we approve these therapies and how we make sure that there is coverage for patients with rare diseases.

This transcript has been lightly edited for clarity.

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