After multiple doctor visits, a slew of lab tests, and an intestinal biopsy, Sarah is diagnosed with Crohn’s disease. Her gastroenterologist prescribes a biologic that could stop the inflammation and improve her quality of life. But instead of starting treatment, Sarah finds herself in limbo. Unclear benefit coverage, missing clinical documentation, and delays in prior authorization (PA) leave her waiting while her symptoms worsen and her trust in the healthcare system erodes. No wonder it’s so difficult to improve patient engagement.
This scenario plays out thousands of times every day. While patients increasingly demand visibility into their healthcare—expecting the same real-time information they get when tracking a package or monitoring their bank account—PA processes continue to keep them in the dark about their own care.
Before treatment can begin, providers, patients, and pharmacists need to overcome a series of PA hurdles.
For example, nearly two-thirds of biologic prescriptions for inflammatory bowel disease are held up by PA delays, often postponing critical treatment for weeks or even months. But the problem extends beyond any single condition or therapy class. Across healthcare, payers, providers, and pharmaceutical manufacturers collectively spend an estimated $94 billion annually managing PAs.
These statistics represent real patients who abandon therapy, real providers burning out from administrative burden, and real health outcomes deteriorating while paperwork gets shuffled between disconnected systems.
While providers struggle with fragmented workflows and payers grapple with cost containment, patients feel like powerless players in the PA process. Information silos prevent real-time communication about benefit coverage and approval status. Manual processes mean patients receive few updates about where their PA request stands or what they need to do next.
The complexity only deepens when patients need specialty medications that may fall under drug benefits, medical benefits, or a combination of both. The lack of standardization between pharmacy and medical PAs—which operate under different workflows and rules—creates a layer of confusion that patients struggle to navigate alone.
The result? Surprise denials arrive with unclear next steps. Patients face costs they weren’t prepared for. And treatment delays stretch on without explanation.
What does patient empowerment look like in the context of prior authorization?
On a recent DHC Group podcast, Colin Banas, M.D., M.H.A., Chief Medical Officer at DrFirst, said, “Not knowing the status of prior authorization is particularly hard on patients.” He emphasized that empowerment requires information, transparency, and support—all of which have been missing from traditional PA processes. Dr. Banas stressed that the following technology-enabled solutions make it possible to bring patients into the conversation:
These solutions integrate directly into existing EHR workflows, addressing friction for providers and simultaneously creating opportunities to improve patient engagement.
The transformation from fragmented, manual processes to coordinated, automated workflows benefits everyone. FHIR APIs and intelligent automation reduce the manual work that currently bogs down providers, payers, and pharmacy teams alike.
But more importantly, this new model recognizes that optimal outcomes require collaboration that includes patients. When patients understand their role in the process and have the tools to participate actively, they may start therapy sooner, abandon prescriptions less often, and adhere more closely to their medication regimens.
Instead of Sarah waiting in the dark for weeks about her biologic PA status—or worse, ending up in the emergency department due to a flare-up—she could receive real-time status updates and clear next steps. As patients continue demanding better healthcare experiences, real-time engagement isn’t just good customer service—it’s essential healthcare strategy.
Download our guide: Unlocking Access to Specialty Medications: The Strategic Power of Smarter Prior Authorization for an in-depth look at automation strategies and ways to improve patient engagement.
To hear more insights, listen to Dr. Colin Banas discuss the intersection of technology and specialty care access on the DHCG Disruptive Dose podcast.