Prior Authorization Requirements Delay, Interfere With Cancer Treatment

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Prior Authorization Requirements Delay, Interfere With Cancer Treatment

By Shari Roan
Everyday Health
May 16, 2019

The majority of radiation oncologists in a new survey said that prior authorizations required by health insurance companies, in which doctors must gain approval for a proposed treatment before treating a patient, delay or disrupt the care of patients. The survey was released on April 25 in a news conference sponsored by several medical organizations seeking to highlight the growing problem.

Among the nearly 700 radiation oncologists surveyed, 93 percent said their patients experienced a delay in receiving life-saving treatment due to prior authorization requirements. Thirty-one percent said the average delay was more than five days.

Previous research has demonstrated that each week of delay in starting cancer therapy results in a 1.2 to 3.2 percent increased risk of death.

The new survey, conducted by the American Society for Radiation Oncology (ASTRO), highlights the real-world impact of the problem, finding that delays and denials cause stress and impact treatment.

More than 7 in 10 radiation oncologists said their patients regularly express concern about the delays caused by prior authorization. More than 3 in 10 radiation oncologists said they have been forced to use a different therapy for a substantial number of their patients due to prior authorizations delays.

About one million Americans undergo radiation treatment for cancer each year, says Paul Harari, MD, chair of ASTRO’s board of directors and head of the human oncology department at the University of Wisconsin in Madison. He calls the prior authorization system “broken.”

“These delays add to the stress of a cancer diagnosis and cause immense patient anxiety,” he says. “Unnecessary third-party review also undermines the judgment of our physicians and patients, and this can lead to real harm.”

Prior Authorization Process Delays Care, Distracts Doctors From Patients

Prior authorization is a long-standing practice that is meant to ensure that patients receive the most appropriate and efficacious treatment, says Vivek Kavadi, MD, vice chair of ASTRO’s payer relations subcommittee and a radiation oncologist at Texas Oncology. But in its current form, many physicians view the system as doing far more harm than good, he says. For example, denials are often appealed and won, allowing the patient to proceed with treatment after an unnecessary delay.

“Nearly two-thirds of radiation denials are overturned on appeal,” Dr. Kavadi says. “This raises serious questions about the reasons for the denial in the first place. Where is the value when we are increasing costs without adding benefit? The process needs to be a productive use of everyone’s time and effort, not just meant to introduce delays and hassle with often no change in treatment.”

More than 4 in 10 radiologists said their reviews are typically not conducted by a licensed radiation oncologist. Moreover, radiation oncology benefit management companies (ROBMs) required 85 percent of radiation oncologists to generate multiple treatment plans as alternatives to the preferred treatment plan, a procedure that requires many hours of extra office work.

Doctor’s office staff spend many hours fighting health insurers for approval of treatments, the survey found. Nearly one in five radiation oncologists said they lose more than 10 percent of time that could be spent caring for patients focused on dealing with prior authorization issues.

An additional 39 percent said they spend from 5 to 10 percent of their average workday on prior authorizations. About two-thirds said they had to hire additional staff in the last year to manage the prior authorization process.

Patients treated at community-based, private practices were found to experience longer delays than those seen at academic centers. Newer treatment modalities typically require prior authorization, but that represents just a fraction of the problem, Kavadi says. Physicians are often required to seek prior authorization for procedures that represent long-held standards of care.

“Prior authorization affects all treatments — even well-established, standard-of-care treatments,” he says.

Not a Problem Limited to Cancer Care

Prior authorization plagues all areas of medicine, not just cancer care. In a survey published on March 12 by the American Medical Association (AMA), 88 percent of 1,000 doctors said that requirements for prior authorization for prescriptions have increased over the past five years. The survey also found that 41 percent of the physicians said requests for prior authorization for medical services had also increased significantly.

Other studies are appearing in medical literature highlighting the burden of prior authorization. A study published in December in the International Journal of Radiation Oncology, Biology, Physics looked at the issue among 444 patients whose oncologists wanted to start proton beam radiation therapy for cancer. The study found that 77 percent of the requests for proton beam therapy were supported by ASTRO policies. However, 74 percent of those patients were initially denied treatment, and 32 percent remained denied after appeal. Prior authorization delayed the start of treatment an average of three weeks — but was as long as four months in some cases.

Medical Organizations Pushing for Reform

Efforts to reform the prior authorization system have gained strength in recent years. Several health organizations and two insurance trade groups issued a joint consensus statement in January 2018 calling for reforms to the prior authorization process.

ASTRO has joined with the AMA, the American Cancer Society Cancer Action Network(ACSCAN), and other health groups to seek reforms in the prior authorization process.

The AMA has also launched a patient petition drive addressing reform. Experts have proposed a detailed list of measures to improve the prior authorization process, including establishing timelines for authorization based on whether the request is urgent (a response required within 24 hours) or nonurgent (a response required within five days), and allowing a prior authorization approval to stand for a given period of time, such as a year, if the treatment or medication needs to be repeated.

Medical organizations have also asked insurers to post online a list of medications and procedures that require prior authorization. High-quality medical centers that regularly meet standard-of-care guidelines and compliance standards should be exempt from the prior authorization process, other experts suggest.

“It’s appropriate to question things that may be unusual or very expensive,” Dr. Harari says. “But to question everything every time is not reasonable or appropriate and doesn’t have any value.”

Some states are enacting prior authorization reforms, according to Bruce A. Scott, MD, vice speaker of the House of Delegates for the American Medical Association and a member of the AMA board of trustees. But there is currently no federal legislation addressing prior authorization reforms.

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