“What was designed to ensure that appropriate care was taking place has now become the means of creating obstacles to the delivery of that care,” noted Vivek Kavadi, MD, Vice Chair of the American Society for Radiation Oncology (ASTRO) Payer Relations Subcommittee and radiation oncologist at Texas Oncology.
In a recent survey, ASTRO found that prior authorization, the process by which clinicians receive payer approval to perform a test or procedure on a patient, has become the biggest challenge facing the field of oncology. The survey found that 93 percent of radiation oncologists said their patients are delayed from receiving life-saving treatments—a delay 31 percent said lasts, on average, 5 days—from prior authorization.
With each day of delay in cancer treatment accounting for between a 1.2 and 3.2 percent increased risk of death, oncologists are urging payers and legislators to rethink the prior authorization process.
Delays in Care
“Prior authorization is about making sure patients are getting the appropriate and most efficacious treatment for their condition and being treated in the most efficient way possible,” Kavadi said. “It was intended to identify if equivalent treatments are possible to prevent the over-utilization of medical care, but it is now so ubiquitous that it is an impediment in the care of many patients.”
The delays from prior authorization, in many cases, result from a requirement of multiple treatment plans, peer review, or some other form of authorization. However, the ASTRO survey found that in most cases, treatments are initially approved and nearly two-thirds (62%) of respondents said that denials are overturned on appeal. “It raises questions to if the motivation of the denial was in the best interest of the patient or not when insurance companies overturn their decisions so often,” Kavadi said.
According to the survey, 44 percent of clinicians needed prior authorization for at least half their treatment recommendations, while an additional 37 percent needed it for more than a quarter of cases.
Eighteen percent of respondents said they lose more than 10 percent of time they could be caring for patients focused instead on dealing with prior authorization issues. Another 39 percent spend an additional 5-10 percent of their workday on prior authorization challenges.
“Ultimately, somewhere along the way, prior authorization became a cost-cutting measure,” Kavadi said. “Whether it was overtly intended or not, the reality is that if something is being done to ensure a patient is being treated correctly, it should be uniform, not a different answer for different insurance companies.”
The survey indicated that private insurers were the most likely type of health care coverage organization to require prior authorization and that patients treated at community-based, private practices experienced longer delays due to prior authorization than those at academic centers.
“There is no reason to think that a patient with insurance company A should be managed with a different set of rules or expectations than for patient insurance company B,” Kavadi said.
Employing Clinical Judgment
However, impartial treatment from insurance companies is not always the case, and those that require prior authorization often cause delays that impact clinician availability for patient care.
For those cases requiring prior authorization, radiation oncology benefit management companies required 85 percent of radiation oncologists to generate multiple treatment plans at some point in the review process, requiring physicians and medical physicists to spend hours developing alternatives to their recommended treatment plans.
“All of us as physicians, through experience, have perspective on which technique to use in which situation,” Kavadi said. “We see a particular patient, review the disease and disease extent, look at the anatomy, and review imaging studies to get perspective on how best to treat patients. That's what's called clinical judgment, and this is why patients like to see physicians that have expertise and experience in a particular field.”
But due to restrictions from prior authorization, oncologists are forced to delay treatment that could save a patient's life. “If you have perspective on how you want to treat a patient, you are now not allowed to go ahead and practice your trade,” Kavadi said. “You're required by the insurance company to prove your judgment is necessary and appropriate.”
Kavadi has found in his practice that generating alternative treatment plans for prior authorization requirements takes the physician and associated teams twice the amount of time at no additional reimbursement.
“The vast majority of the time, original treatment plans are ultimately approved. [Generating alternative plans] ends up being nothing more than wasted time,” he said, echoing the survey results. “We as physicians are expected to practice evidence-based medicine that comes from our scientific knowledge and, to an extent, is based on guidelines that we follow.
“Those guidelines are in place and published in the public domain until new science comes in and informs another guideline. If scientific evidence is present and we are following guidelines, why must we re-litigate these questions every time a patient needs to have treatment?” he asked.
For example, Kavadi noted, if a patient needs to have treatment for colorectal cancer, he or she will be treated with a particular form of radiation and a particular form of chemotherapy. “If a guideline has been in practice for 25 or more years, why is it that I need to ask for permission to do that treatment? There should be something such as settled science.”
For patients, the frustration from such a delay is shared. “Prior authorization often now causes delays in treatment, which results in anxiety and has a potential risk for making treatment less efficacious, causing a greater risk to the patient in terms of their overall health outcome,” Kavadi said.
“Cancer patients have a tremendous amount of anxiety with their diagnosis,” he added. “Patients with cancer want to get their diagnosis as quickly as possible and start treatment as quickly as possible. They are able to calm down when they realize that someone has identified the problem and how best to treat it, but if anything causes a delay, such as prior authorization, all it does is cause added anxiety.”
Survey respondents agreed—73 percent said their patients regularly express concern to them about the delay caused by prior authorization. “Patients with cancer have already been beaten down sufficiently. On some level, patients whose treatment is delayed by prior authorization find a resignation that this is how the world is. Being delayed inordinately forces some patients to the point of reluctance and forces them to live with the situation,” Kavadi said.
In his practice, Kavadi said the delays from prior authorization have forced patients to extreme measures to receive care. He shared the story of a patient who had received prior radiation treatment for breast cancer but found a new malignancy in the same breast years later. She was not a candidate for repeat conventional radiation but could have partial radiation to save her breast.
“Her physician and team did everything they could to get coordinated, but the approval of her prior authorization was declined, denied, and delayed. Ultimately, the patient went forward and had the treatment for fear that her window of opportunity to be saved would be lost.” The patient paid over $100,000 in out-of-pocket costs for the treatment and is still appealing the treatment with her insurance company, Kavadi said.
“In this case, the patient had to make a decision between her health and her financial well-being. She was in a position in which she could pay for the treatment, but the vast majority of patients are not able to do that,” he said. “Her treatment could have been compromised.”
Kavadi noted that these types of delays are not isolated to one modality and often spread to the overall care of the patient. “Chemotherapy and radiation are the standard therapy for head and neck cancer, gastrointestinal cancer, gynecologic cancer, and many others. There is clear-cut evidence that, as you delay treatment, tumors progress quickly and the patient's outcome is worse,” he said. “When physicians are following guidelines, we shouldn't have to prove it to the insurance companies.”
Seeking Regulatory Relief
To combat the risk of patient well-being, wasted time, and other burdens introduced by prior authorization, bipartisan legislation is seeking to modify insurance requirements.
Recently, the Prior Authorization Process Improvement Act was referred to the Ways and Means Committee but got no further. The bill sought to “require the Secretary of Health and Human Services to submit a report to Congress within a year on the feasibility of Medicare Advantage organizations and providers and suppliers of services using certain technologies to facilitate the administration of prior authorization requirements under Medicare Advantage plans offered by such organizations.”
It called for the secretary to consult with an advisory panel of organizations, providers, and suppliers of services; beneficiary representatives; and technology vendors in preparing the report. Though the bill was halted, new legislation is expected to be released in the House of Representatives within the year.
“Prior authorization is a systemic problem within the practice of medicine in the U.S.,” Kavadi said. “What was in theory a worthwhile cause has completely blossomed out of control and it requires regulatory relief. Patient treatment shouldn't be based on what insurance they have, but on the correct treatment for them.”