Nearly one-third of radiation oncologists surveyed in a study released by the American Society for Radiation Oncologists (ASTRO) said that delays related to prior authorization (PA) have changed the course of treatment they selected for their patients.1
PA is a utilization management technique commonly used by health insurers to reduce medication waste and keep costs manageable. But based on the survey responses from 673 radiation oncologists, use of PA requirements increased patient stress, wasted a physician’s time, and had a “disproportionate impact on patients at community-based clinics.”1
Vivek Kavadi, MD, vice chair of ASTRO’s payer relations subcommittee and medical director of radiation oncology at US Oncology, told Cancer Therapy Advisor that “The burden of prior authorization seems to fall more on those practices with fewer resources to manage the excessive administrative work needed to obtain prior authorization approvals. Smaller departments, by definition, have fewer people available to take on this additional work.”
These treatment delays can become compounded when a PA is denied, and most of those denials serve to further delay care. This postponement seems particularly egregious when one considers that the radiation oncologists reported that 62% of PA review denials are eventually overturned on appeal.
“There tend to be more prior authorization hurdles for more expensive treatments, but many standard, ‘less expensive’ treatments are undergoing prior authorization review, as well,” said Dr Kavadi. And patients with cancer often receive multiple treatments; this fact can further compound the PA problem.
The consensus statement, which is backed by 6 organizations — the American Hospital Association, America’s Health Insurance Plans, the American Medical Association, the American Pharmacists Association (APhA), BlueCross BlueShield Association, and the Medical Group Management Association — offered 5 areas of opportunity to improve PA programs:2
- Selective application of prior authorization
- Prior authorization program review and volume adjustment
- Transparency and communication regarding prior authorization
- Continuity of patient care
- Automation to improve transparency and efficiency
Under these 5 main categories, there are specific terms of agreement. Notable agreements include the pledge to stratify PA requirements based on “health care providers’ performance and adherence to evidence-based medicine,” and to allow the criteria for PA to be transparent and accessible to contractors.
Also, the consensus agreement said PA requirements should be reviewed regularly. They should also be adjusted to facilitate the addition of “new and emerging therapies, where prior authorization may be warranted due to a lack of evidence on effectiveness or safety concerns” and to remove outdated PA restrictions, the statement authors wrote. 2
Authors of the consensus statement also called for the agreement to encourage protections for continuity of care for patients, and to make PA requirements and formulary information available electronically at the point of care so that health care providers have the “coverage information they need when making treatment decisions.”2
To see all of the specifics included in the consensus statement, please visit the links to the original sources.
- American Society for Radiation Oncologists (ASTRO). Prior authorization obstacles unnecessarily delay patient access to cancer treatments, physician survey finds [press release]. Published April 25, 2019. Accessed May 1, 2019.
- American Society for Radiation Oncologists (ASTRO). Consensus statement on improving the prior authorization process. Accessed May 1, 2019.