As medications become more intricate and expensive, medication access barriers prevent patients from acquiring their prescriptions and continuing medication regimens. The prior authorization (PA or prior auth) process is one of the access obstacles patients face when trying to acquire their medications.
The prior authorization process, a cost management tool employed by health insurance companies, requires providers to request permission to prescribe a particular medication or service. As a result of the prior authorization process, providers spend more time completing administrative duties, and patients experience delays in care.
The prior authorization process harms patient access and the provider-patient relationship, which forms the foundation of trust for the healthcare system. Without strong provider-patient communication, patients are less likely to fill their medications and adhere to a prescription routine. According to key opinion leaders (KOLs), prior authorization reform is urgently needed.
A team of healthcare providers is required to educate and assist patients in accessing their medication. In particular, a prior authorization specialist is essential to help patients obtain the best medication and maintain their therapy regimen even if the patient has a change in health insurance plans.
Understanding the obstacles patients face while obtaining and taking medications is essential for health care providers (HCPs), market access specialists, health economics and outcomes specialists (HEOR), or medical affairs specialists to assist patients with medication adherence. Here we will discuss the difference between medication compliance and medication adherence, why patients don’t take their medications, and the impact of prior authorization on medication compliance and adherence.
Medication Compliance vs. Medication Adherence
Medication compliance and adherence are terms used to describe how patients take their medications and are often utilized interchangeably. However, there are subtle differences between them. Patient compliance refers to whether the patient follows the prescriber’s advice and obeys the physician.
In contrast, adherence emphasizes the collaborative nature of the provider-patient relationship. The prescriber and patient must discuss the best treatment to ensure patient adherence. As a result, the patient is not obliged to accept a particular treatment and is not solely responsible for non-adherence to a treatment plan.
According to this definition, adherence lies in the “extent to which the patient’s behavior matches with the prescriber’s recommendations”3 Adherence is used more frequently than compliance to emphasize healthcare’s cooperative nature. A collaborative approach to medicine adherence requires outstanding communication skills. Patients may not adhere to medication if they receive confusing or conflicting information.
Barriers to Medication Adherence
Communication barriers between patients and providers are not the only obstacles patients face when taking medications.2 Patients’ ability to adhere to medications depends on patient-related and treatment-related barriers.5
Patient-related barriers refer to aspects of a patient’s social determinants of health (SDOH), which include the following:
- Transportation, housing, and neighborhood safety
- Violence, racism, and discrimination
- Income, education, and employment
- Access to healthy foods
- Participation in physical activity
- Air and water pollution
- Literacy and language skills
Medication non-adherence is primarily caused by patients forgetting to take medications.5
According to a recent study, almost 50% of patients cited forgetfulness as the primary non-intentional reason for non-adherence.5 The results of this study emphasize the importance of social support for patients, especially those with mental health or memory problems, and the importance of artificial intelligence (AI) in helping patients remember to take their medications.
Along with patient-related barriers, treatment-related obstacles significantly impact a patient’s ability to obtain medication from the pharmacy and adhere to a medication regimen. Figure 1 illustrates the six treatment-related barriers experienced by patients.
Figure 1: Common treatment-related barriers to medication adherence
Prior authorization is considered an access obstacle as it delays or prevents patients from receiving their initial dose of medication. Even if a patient can acquire their initial dose of medication, they may not adhere to the medication if they switch insurance and have to undergo the prior authorization process again. Additionally, patients’ health insurances may employ step therapy, the “fail-first policy,” making patients take a less expensive medication before “stepping up” to a more expensive therapy.
Step therapy requires patients to suffer side effects and reduce their quality of life before receiving prior authorization for more expensive drugs. For patients with insurances requiring step therapy, treatment-related barriers are compounded, requiring patients to endure both access obstacles and side effects. A 2019 study found that patients with rheumatoid or psoriatic arthritis and insurance plans requiring step therapy were less likely to adhere to medications.1 As barriers increase, patients are less likely to adhere to their prescriptions, resulting in devastating consequences.
Impact of Medication Adherence Barriers
Medication adherence can influence patient outcomes more directly than the treatment type.4 Medication adherence can affect quality and length of life, health outcomes, and healthcare costs. The illustration below depicts four adverse effects of access obstacles and other treatment-related barriers on patients and the U.S. healthcare system.
1. Increased Healthcare System Costs
Approximately 125,000 deaths and 25% of hospitalizations occur due to medication nonadherence in the United States. While health insurance companies and the players of prior authorization insist prior authorization and step therapy reduce health care costs, many studies have determined these cost management tools increase the overall cost of healthcare. Every year, medication nonadherence costs $100 billion to $289 billion.
2. Reduced Treatment Efficacy
Typically, an adherence rate of 80% or more is needed for optimal therapeutic efficacy, yet only 50% of chronic disease patients adhere to their medication.4 As time passes and barriers arise, adherence rates decline. In a recent survey, 75% of physicians said the prior authorization process has led to prescription abandonment.
3. Increased Adverse Events
Prior authorization can increase prescription abandonment by nearly 40%, and prescription abandonment increases the risk of adverse event problems or hospitalization. Consequently, the prior authorization process is responsible for increased adverse health events.
4. Increased Hospital Visits
The likelihood of a patient visiting an emergency department (ED) or urgent care increases as medication adherence decreases.8 Studies have shown that nearly 8% of ED visits are related to medication non-adherence. There is a high cost associated with treating “ED super-utilizers,” who represent only 3-5% of the U.S. population but account for 30-50% of the total ED budget.
According to CoverMyMeds, an electronic prior authorization solution company, patients are more likely to adhere to their medication regimen if an electronic solution is utilized to ensure prescriptions are available at the pharmacy. Data shows that adopting electronic prior authorization through electronic health record (EHR) systems correlates with a decrease in time to therapy and, overall, an increase in patient medication adherence.
Additionally, pharmacists play a crucial role in improving medication adherence. Pharmacists are a source of drug education and facilitate access to medications. Prior authorization specialists or pharmacists with prior authorization knowledge are best qualified to help patients obtain their medications and improve medication adherence. To learn more about becoming a prior authorization specialist or certifying your team, visit the National Board of Prior Authorization Specialists homepage.
1. Boytsov, N., Zhang, X., Evans, K.A. et al. Impact of Plan-Level Access Restrictions on Effectiveness of Biologics Among Patients with Rheumatoid or Psoriatic Arthritis. PharmacoEconomics Open 4, 105–117 (2020). https://doi.org/10.1007/s41669-019-0152-1
2. Burnier M, Egan BM. Adherence in Hypertension. Circulation Research. 2019;124(7):1124-1140. doi:10.1161/circresaha.118.313220.
3. Chakrabarti S. What’s in a name? Compliance, adherence, and concordance in chronic psychiatric disorders. World J Psychiatry. 2014;4(2):30-36. doi:10.5498/wjp.v4.i2.30.
4. Jimmy B, Jose J. Patient medication adherence: measures in daily practice. Oman Med J. 2011;26(3):155-159. doi:10.5001/omj.2011.38.
5. Kleinsinger F. The Unmet Challenge of Medication Nonadherence. Perm J. 2018;22:18-033. doi:10.7812/TPP/18-033.
6. Simon ST, Kini V, Levy AE, Ho PM. Medication adherence in cardiovascular medicine. BMJ. 2021;374:n1493. Published 2021 Aug 11. doi:10.1136/bmj.n1493.
7. Walsh CA, Cahir C, Tecklenborg S, Byrne C, Culbertson MA, Bennett KE. The association between medication non-adherence and adverse health outcomes in aging populations: A systematic review and meta-analysis. Br J Clin Pharmacol. 2019;85(11):2464-2478. doi:10.1111/bcp.14075.