Implementation and workload impact of a Veterans Integrated Service Network (VISN) centralized prior authorization program.

Abstract

Purpose: This retrospective study evaluated the primary objective of whether centralizing prior authorization drug request (PADR) adjudication across 4 Veterans Integrated Service Network (VISN) 21 healthcare systems reduced local pharmacist workload while maintaining or improving timely prior authorization completion. The study was determined to be institutional review board exempt.

Summary: In 2019, VISN 21 piloted a centralized PADR program, funded by the Veterans Health Administration Pharmacy Benefit Management. The program aimed to standardize prior authorization processes, promote pharmacoequity, and reallocate healthcare system (HCS) clinical pharmacy specialists' time toward increasing patient access. A retrospective analysis compared prior authorizations processed 6 months before and 6 months after centralization. Before centralization, 10,922 prior authorizations were adjudicated by 161 clinical staff members (8 pharmacist full-time equivalents [FTEs]), with 95% of the prior authorizations completed within 96 hours. After centralization, 10,779 prior authorizations were handled by 6 VISN staff FTEs (4 pharmacists and 2 technicians), achieving a 98% completion rate within 96 hours. This HCS-to-VISN prior authorization workload shift enabled HCS clinical pharmacists to devote an additional 3,100 hours to patient care.

Conclusion: The centralized PADR program in VISN 21 significantly reduced HCS-level administrative burden and improved patient access by increasing clinical pharmacist availability for clinical responsibilities. Centralization reduced the required number of FTEs for prior authorization adjudication by 25%, improved turnaround time by 3.6%, and ensured standardized adjudication practices. This initiative demonstrates an effective strategy to standardize prior authorization adjudication and improve care delivery efficiency within VISNs and across the national Veterans Affairs system.