'Inhumane': Prior Authorization Puts Cancer Patients at Risk

Kristin Jenkins

May 01, 2019

"Honestly, why do you need prior authorization for my cancer treatment? It is not elective!"

An exasperated patient undergoing radiation at Texas Oncology in Webster, Texas, represents the frustration of many patients across the United States when prior authorization processes delay the start of cancer therapy, says Vivek Kavadi, MD, a radiation oncologist at the practice.

Kavadi should know. As the vice chair of the Payer Relations Subcommittee at the American Society for Radiation Oncology (ASTRO), he hears a lot complaints from US physicians about what the prior authorization process is doing to their practice and their patients.

"I work in a cancer center where the radiation treatment area is in the same location as chemotherapy infusion," Kavadi writes in his blog. "This provides for seamless coordination and patient convenience."

However, prior authorization requirements for radiation put carefully coordinated plans for combining daily radiation and multiple infusions on hold — for a week or two. In the meantime, the patient with cancer waits…

Now, results from an ASTRO survey on prior authorization confirm that the prior authorization practices of health insurers in the US have mired radiation oncologists in red tape and are negatively impacting outcomes for patients with cancer.

Instead of ensuring that patients with cancer get the best treatment in the most efficient way, as intended, prior authorization creates obstacles to patient care, the survey shows.

Out of 673 radiation oncologists who responded, 93% said that prior authorization unnecessarily delays potentially life-saving cancer treatment by placing time-wasting demands on them, derailing treatment, and creating a disproportionate burden for patients seen at community-based practices.

"The system is made to put off treatment for days at a time, which is very unfortunate," said one clinician in an online summary of physician testimonials culled from the survey. "It is not right, it is inhumane."

Some 31% of radiation oncologists surveyed said that prior authorization delays treatment for 5 days or more and 32% said they were forced to use an alternative treatment in more than 10% of their patients.

These delays and treatment changes created even more stress for patients with cancer who were already anxious about their health, according to 73% of radiation oncologists in this representative sample of national membership.

Cause for Alarm

At an April 25 online press briefing, Paul M. Harari, MD, chair of the ASTRO Board of Directors, called the findings "cause for alarm."

Harari is the Jack Fowler Professor and Chairman of the Department of Human Oncology at the University of Wisconsin School of Medicine and Public Health in Madison.

This survey makes it clear "that restrictive prior authorization practices can cause unnecessary, stressful, and potentially life-threatening delays for cancer patients," he said.

Harari noted that research findings from the Cleveland Clinic show that each week of delay in initial cancer therapy is associated with a 1.2% to 3.2% increase in mortality risk, depending on cancer type.

"While the system may have been designed as a path to streamline and strengthen healthcare, it is in fact frequently harmful to patients receiving radiation therapy," Harari said. "In its current form, prior authorization causes immense anxiety and wastes precious time for cancer patients."

Prior authorization causes immense anxiety and wastes precious time for cancer patients. Dr Paul Harari

This latest ASTRO survey was conducted as an add-on to the 2018 annual national survey after 9 out of 10 radiation oncologists identified "getting prior authorization" as the biggest challenge they currently face in clinical practice.

This subsequent survey, sent to all 3882 radiation oncologists in ASTRO's member database, quantifies the burden that prior authorization places on physicians and patients alike.

Interference in cancer care decisions has hit radiation oncologists particularly hard, said Kavadi.

"Radiation oncologists increasingly are restricted from exercising our clinical judgment in what is in the best interest of the patient, yet we are held accountable for the outcomes of treatments where decisions have been taken out of our hands," Kavadi pointed out.

In the survey, 44% of radiation oncologists said they needed prior authorization for at least half of their treatment recommendations, and another 37% needed it for at least a quarter of their cases.

A total of 39% said they spent 5% to 10% of their average workday dealing with prior authorization issues and 63% said they had to hire more staff just to manage the process.

Some 85% of radiation oncologists said they were required to generate multiple treatment plans, providing alternative therapeutic strategies to their recommended course of treatment. 

One physician noted that this "places stress on [radiation oncologists] to get multiple plans done quickly — rushing an already complicated process."

Other survey respondents said requests for "rapid review" took so long that patients with severe acute problems such as obstructive or painful tumors died while waiting for treatment authorization.

One clinician with a 32-year-old patient with cervical cancer and bleeding said final approval for a treatment plan submitted on an urgent basis took 4 weeks. As a result, the patient had to begin therapy overcome with anxiety about whether her insurance company would help defray the costs.

In other physician testimonials, three patients with prior authorization actually completed their care only to have coverage revoked later, leaving all three with 100% financial liability.

Even though nearly two thirds of denials are overturned on appeal, peer-to-peer reviews are usually conducted by someone who is not a radiation oncologist, said 44% of survey respondents.

After being informed that "the policy is to reject this," they said they were left without any way to discuss the case, provide medical judgement, or expedite treatment.

"[This] is not a fair representation of what 'peer-to-peer' should be," commented one clinician.

Delays in securing prior authorization and treatment disproportionately affected patients seen by radiation oncologists working in a community-based private practice. Some 34% of these clinicians said their patients faced delays lasting longer than 1 week compared with 28% of radiation oncologists working in an academic setting (P = .005).

Similarly, 23% of radiation oncologists working in community-based settings said they spent more than 10% of their day focused on prior authorization. By comparison, only 13% of physicians working at academic centers were burdened to the same extent (P = .003).

These findings support recent reports from the American Medical Association (AMA), the American Cancer Society Cancer Action Network (ACS CAN), and others showing that prior authorization affects patients and clinicians across the entire healthcare system.

At the online press conference, Bruce Scott, MD, vice speaker for the AMA House of Delegates and a member of the AMA Board of Trustees, presented results from the AMA's December 2018 survey of 1000 clinicians. The AMA survey results mirror those of the ASTRO survey.

Scott, who is an otolaryngologist and facial plastic surgeon based in Louisville, Kentucky, emphasized that "now is the time to fix prior authorization."

The AMA survey results show that 86% found prior authorization to be a "high or extremely high" burden, with 91% reporting that they associated care delays with negative patient outcomes. Of the respondents, 60% were specialists.

Notably, 75% said that issues related to prior authorization led patients to abandon their recommended treatment. What's more, 28% said prior authorization led to serious adverse events such as death, hospitalization, disability/permanent bodily damage, or some other life-threatening event.

On average, the AMA survey showed that each physician spent an average of 14.9 hours or 2 business days each week processing an average of 31 prior authorization submissions.

Recently, ASTRO joined the AMA and other medical organizations concerned about the negative impact of prior authorization on patient outcomes by signing the Roe-Bera prior authorization letter.

The underlying assumption was that utilization management concepts such as prior authorization are here to stay for the foreseeable future, said Scott.

The letter calls for the Centers for Medicare & Medicaid Services (CMS) to regulate prior authorization requirements to align with a consensus statement released by the AMA in January 2018.

The consensus statement was authored jointly by the AMA and leading provider and payer organizations such as the American Hospital Association, the American Pharmacists Association, and the Blue Cross Blue Shield Association.

In it, the group states that criteria should be developed to selectively apply prior authorization, with regular program review to identify therapies that no longer warrant prior authorization. An effective two-way communication channel is also needed between payer, physician, and patient.

Continuity of care must be provided for patients on active treatment who are faced with a formulary or treatment coverage change, the group says. Similarly, patients on chronic, established therapy must continue to have access to prescription medication.

To streamline the prior authorization process and increase efficiency, the consensus is that electronic transactions based on existing national standards should be used.

"This issue remains at the forefront for radiation oncologists and the entire house of medicine…" ASTRO's Kivadi noted in his blog. "This issue affects us all."

Physicians can follow the conversation on prior authorization obstacles to patient care at #ASTROadvocacy and share their stories on the AMA's grassroots website #FixPriorAuth.

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