In a study of more than 1000 patients with gynecologic cancer, 25% required prior authorization by their insurance for some part of their cancer care, and this resulted in delays or changes in care.
“[T]his study quantifies a national problem [in the United States], and it is the first analysis to provide this insight in the field of gynecologic oncology,” the study authors wrote. They reported their findings in the journal Gynecologic Oncology.
The retrospective study included data from 1406 patients treated at University of Pennsylvania gynecologic oncology practices. The patients had 2112 clinic visits during a 3-month period in 2021. Data from electronic medical records were used to evaluate the incidence of prior authorizations during the 3-month period and prior to it.
In the overall cohort, 56.2% of patients had private insurance, 32.4% had Medicare, 11% had Medicaid, and 0.1% were uninsured. The majority of prior authorizations occurred among patients with private insurance (63.5%), followed by Medicaid (18.9%) and Medicare (17.6%).
Overall, 24.6% of patients required a prior authorization at some point during their cancer care. This included 74 patients who required prior authorizations during the 3-month study period and 272 who had prior authorizations before that period.
There were a total of 83 prior authorization requests during the 3-month period. Most were for imaging (50.6%), followed by supportive medications (28.9%) and chemotherapy (16.9%).
The reasons listed for requiring prior authorization included:
- Care deemed medically unnecessary (33.7%)
- Out-of-network provider for imaging or molecular testing (10.8%)
- Need for additional information (9.6%,)
- Therapy not approved by the US Food and Drug Administration (3.6%)
- Alternative imaging recommended (2.4%)
- Not on formulary (2.4%)
- No reason given (37.3%).
A majority of prior authorization requests were appealed (97.6%), and most (79%) were approved. Most appeals (66.1%) required a peer-to-peer phone conversation for approval.
There were 17 denials after appeal. In 3 cases, this led to a substantial change in care, such as the patient not receiving planned chemotherapy or surgery.
For cases in which prior authorizations were approved, the mean time from order placement to care delivery was 16 days (range, 0-98 days), and the mean time from prior authorization approval to care delivery was 6.4 days (range, 0-51 days).
“In our study of 1406 patients, 1 in 4 patients experienced prior authorization during their gynecologic oncology care,” the authors summarized. “While 80% of the prior authorization requests were approved, patients experienced an average 2-week delay in cancer care. Reform of the prior authorization process is essential to improve delivery of necessary cancer care.”
Bodurtha Smith AJ, Mulugeta-Gordon L, Pena D, et al. Prior authorization in gynecologic oncology: An analysis of clinical impact. Gynecol Oncol. Published online October 13, 2022. doi:10.1016/j.ygyno.2022.10.002