Prior Authorization Hurdles Delay Oncology Care

Prior authorization on cancer treatments is delaying patient care, affecting outcomes, and diverting providers from patient care according to results of a survey conducted by the Association for Clinical Oncology an affiliate organization of the American Society of Clinical of Oncology (ASCO).¹

Three hundred participants completed the 18-question survey between June 27 and July 30, 2022. Approximately half of the participating practices (52%) had dedicated staff working exclusively on prior authorization and 56% responded that they complete 50 or fewer authorizations per week with 47% practices spending more than 40 hours per week on authorizations alone.¹

Significant delays in care, defined as more than 1 business day, were reported by 42% of participating practices. The patient harms because of these delays included delay of treatment (96.25%), delay of diagnostic imaging (94.06%), patient forced to receive second-choice therapy (92.58%), increased out-of-pocket costs (87.94%), and denial of therapy (86.76%). Loss of life was reported by 36.61% of respondants.¹

“Prior authorization is consistently identified as the largest barrier to care for insured patients,” a position paper released by the ASCO noted.² “The administrative burdens associated with prior authorization contribute to major delays and denials of necessary, appropriate—in many cases, lifesaving—care. Providers and patients have offered to collaborate on reforms to prior authorization processes, but these calls have largely gone unheard.”

Other cited consequences of prior authorization delays included disease progression (79.86%), patient forces to alternative treatment (79.78%), denial of genetic testing (76.45%), hospitalization or emergency department visit (73.63%), denial of supportive care (72.00%), patient abandoning care (63.94%), and denial of cancer screenings (61.34%).¹

The average time for a payer to respond, according to the survey results was 5 days with 34% of staff members needing to escalate the request. In terms of completion, 56% of respondents state that a prior authorization which does not go beyond the initiating staff member takes approximately 1 hour or less. Submissions that go beyond the first staff member take approximately 3 hours or less (63%).¹

Medical oncology was the primary clinical practice for 55% of practices. Settings of the participants were well balanced across community or hospital-based health network (35%), private practice (34%), and academic or university (29%).¹

Results of a similar survey conducted by the American Medical Association in 2021, reported similar results to the oncology-specific respondents. Process delays were attributed to delays in care by 93% of respondents (n = 1004) with 34% of physicians surveyed noting that prior authorization led to a serious adverse event and 24% responding that patients were hospitalized due to delays in care.³

Delays in time to treatment initiation has been linked to worse survival outcomes for patients with an absolute increased risk of mortality ranging from 1.2% to 3.2% for every week that treatment is delayed in the curative setting.⁴ Though a variety of factor determine delays in care, alleviating wait times because of prior authorization has been an issue that organizations have supported and attempted to tackle in recent years.^4-6

For example, in 2017, the ASCO released a recommendation that prior authorization policies be streamlined to avoid delays and to ease administrative burdens on practices.⁵ In the updated statement, authors noted that efforts to work collaboratively on prior authorization efficiencies have not resulted in any change.²

Results of the survey highlighted some of the issues presented in the 2017 recommendation including standardization and administrative hurdles faced by practices such a burdensome documentation to demonstrate necessity, response delays, obstructive appeal processed, lack of clinical expertise by prior authorization reviewers, and lack of transparency in process. Nearly all participants in the 2022 survey cited these as hurdles to obtaining prior authorization at a rate of 97%, 97%, 94%, 91%, and 91%.^1,5

An inch of progress was reported in September 2022 with the United States House of Representatives passing the Improving Seniors’ Timely Access to Care Act of 2022.⁷ Under the provisions of the bill, Medicare Advantage plans are required to complete the following:

1. “Establish an electronic prior authorization program that meets specified standards, including the ability to provide real-time decisions in response to requests for items and services that are routinely approved.
2. Annually publish specified prior authorization information, including the percentage of requests approved and the average response time.
3. Meet other standards, as set by the Centers for Medicare & Medicaid Services, relating to the quality and timeliness of prior authorization determinations.”⁷

In the final open-ended question of the survey, participants noted which services they would like to provide at their practice if they could reallocate prior authorization resources. Responses included, see more patients, expansion of supportive care services, onboarding more nurse navigators or advanced practice providers, provide outpatient services, research, and the ability to provide more palliative care.¹

From a cost perspective, the ASCO position statement cited data from an administrative report from the Council for Affordable Quality Healthcare, which found that $528 million was spent on prior authorization processing in 2019 and that time spent per authorization increased 5 minutes (16 to 21 minutes) between 2018 and 2019.^2,8 Additionally, the report highlighted that 35% of prior authorizations were relied on fully manual processes including phone, fax, email, or mail submission; only 26% were fully electronic. the estimated savings with conversion to a fully electronic process would exceed $400 million annually.⁸ ASCO noted that the move to electronic filing is only one step in the process, but one that may improve transparency and physician burden.²

In the clinical setting ASCO recommends that stakeholders “continue to explore incentives to support smaller, under-resourced providers in adopting and implementing a more streamlined prior authorization process [and] ensure evidence-based care through education, clinical decision support tools, and quality improvement campaigns…that improve physician-patient communication of treatment goals and reduce or eliminate unnecessary medical tests and procedures.”

In the final open-ended question of the survey, participants noted which services they would like to provide at their practice if they could reallocate prior authorization resources. Responses included, see more patients, expansion of supportive care services, onboarding more nurse navigators or advanced practice providers, provide outpatient services, research, and the ability to provide more palliative care.¹

References

1. ASCO prior authorization survey summary. Association for Clinical Oncology. November 2022. Accessed November 22, 2022. bit.ly/3EU9SpG
2. ASCO position statement: prior authorization. American Society for Clinical Oncology. Accessed November 22, 2022. bit.ly/3ExHCYI
3. 2021 AMA prior authorization (PA) physician survey. American Medical Association. Accessed November 22, 2022. bit.ly/3ViagDR
4. Khorana AA, Tullio K, Elson P, et al. Time to initial cancer treatment in the United States and association with survival over time: an observational study. PLoS One. 2019;14(3):e0213209. Published correction in PLoS One. 2019;14(4):e0215108.
5. ASCO. ASCO statement on the impact of utilization management policies for cancer drug therapies. J Oncol Pract. 2017;13(11):758-762. doi:10.1200/JOP.2017.024273
6. Press kit: prior authorization obstacles to cancer patient care. American Society for Radiation Oncology. Accessed November 23, 2022. bit.ly/3TWi6lu
7. Improving Seniors' Timely Access to Care Act of 2022, HR 3173, 117th Cong (2021-2022). Accessed November 23, 2022. https://www.congress.gov/bill/117th-congress/house-bill/3173
8. 2021 CAQH Index. Council for Affordable Quality Healthcare. Accessed November 23, 2022. bit.ly/3V6dACu