A new pharmacy-led prior authorization (PA) model implemented at Orlando Health Cancer Institute has demonstrated significant improvements in patient care access and clinical efficiency, potentially offering a blueprint for healthcare institutions nationwide struggling with insurance approval delays.
The innovative approach, which shifts the administrative burden of prior authorizations from clinical staff to a dedicated pharmacy team, has increased medication approval rates from 93.5% to 97.4% while dramatically reducing wait times for cancer patients needing critical treatments.
"With prospective PA, we can get approvals within 24 hours before the prescription even leaves the cancer center," explained Andrea Ledford, PharmD, MBA, BCOP, BCSCP, FASHP, FHOPA, senior pharmacy director of oncology services at Orlando Health Cancer Institute, who presented the findings at the ACCC 51st Annual Meeting & Cancer Center Business Summit.
The Growing Prior Authorization Challenge
Prior authorization requirements have become increasingly burdensome in oncology care, with research showing the average approval time has increased to approximately 14 days. According to a JAMA study, 91% of physicians report negative clinical outcomes due to these delays, with 22% of patients never receiving their prescribed therapy at all.
The problem has expanded beyond expensive cancer medications to include even low-cost supportive care drugs. "Even inexpensive medications that patients are prescribed to help them get through their cancer treatments or improve their quality of life—such as anti-nausea medications, pain medications, antibiotics—even medications that cost less than $30 a month now all require prior authorization," Ledford noted.
These delays create significant challenges for both patients and healthcare providers. Clinic congestion increases as staff members spend valuable time on administrative tasks rather than patient care, leading to longer wait times and reduced operational efficiency.
The Pharmacy-Led Solution
Orlando Health's innovative model centralizes the prior authorization process under the pharmacy department, utilizing specially trained pharmacy technicians who access electronic medical records to handle insurance communications and documentation requirements.
The approach focuses on prospective prior authorization—seeking approval before prescriptions leave the cancer center—rather than the traditional retrospective method. This proactive strategy has dramatically reduced approval times to less than 48 hours for most medications, compared to the industry average of 14 days.
Key components of the model include:
Specialized Training and Remote Work Options
Pharmacy technicians undergo a six-month training period in clinics before having the option to work remotely. This flexibility has contributed to remarkable staff retention.
"I haven't had anyone leave the pharmacy tech team in 18 months," Ledford reported. "They have an axe to grind with the payers too, so they're motivated to push things along."
Streamlined Communication
The team utilizes secure health messaging between groups to expedite communication compared to traditional phone calls. This system allows for faster resolution of issues and better coordination between pharmacy staff and clinicians.
Expanding Role of Clinical Pharmacists
Building on the program's success, clinical pharmacists are now being integrated into peer-to-peer reviews and appeals processes, particularly for targeted therapies. This further reduces the burden on oncologists and advanced practice providers.
"Our next steps include having our clinical pharmacists actually do the peer-to-peer and the appeal process and pull that off of the medical oncologists and the advanced practice providers as well," Ledford explained.
Measurable Benefits for Patients and Providers
The transition to a pharmacy-led model has yielded multiple benefits:
Improved Patient Experience
Patients receive their medications faster, with less time spent waiting in exam rooms while staff negotiate with insurance companies. This leads to more timely treatment initiation and better management of symptoms.
"We want them to feel like they have started their journey to recovery as fast as possible," Ledford emphasized.
Enhanced Clinical Efficiency
By removing administrative burdens from clinical staff, the model allows physicians, nurses, and medical assistants to focus on direct patient care. This has reduced clinic congestion and improved overall operational efficiency.
"It was an advantage for the pharmacy team, the clinic team, and most importantly, the patients," Ledford concluded. "Everyone benefits when we remove these barriers to care."
Staff Satisfaction and Retention
The program has contributed to improved staff satisfaction across disciplines. Clinicians appreciate being able to focus on patient care, while pharmacy technicians benefit from clear roles and remote work options.
Ongoing Challenges and Future Directions
Despite the program's success, new challenges continue to emerge. Insurance companies are increasingly requiring peer-to-peer reviews for drugs approved under expedited FDA pathways, which account for approximately 95% of new oncology medications. Additionally, some payers are now imposing dose rounding protocols.
"They're not just telling us what drugs to use anymore; they're telling us what doses to prescribe," Ledford observed.
The team is also facing technical challenges as insurance companies move away from common portals to proprietary platforms, requiring multiple logins and creating additional administrative hurdles.
Looking ahead, Ledford advocates for broader changes in the prior authorization landscape: "If the cost of the drug is below a certain price point, then prior authorization shouldn't be required if the drug costs the insurance company less than $30 a month. Because it is just creating a huge amount of administrative burden and, quite frankly, the detriment is to the patient."
For institutions considering similar models, Ledford recommends clear communication and relationship-building between team members to ensure smooth handoffs and patient care continuity. She also emphasizes the importance of establishing and communicating standard turnaround times to set appropriate expectations.
As prior authorization requirements continue to evolve, this pharmacy-led model offers a promising approach to mitigating delays and improving patient outcomes in oncology care. The success at Orlando Health Cancer Institute demonstrates that innovative, interdisciplinary solutions can effectively address one of healthcare's most persistent administrative challenges.
