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Doctors surveyed by the Association for Clinical Oncology said payer prior authorization can cause disease progression and loss of life.
Prior authorization is harming people with cancer, said doctors who responded to a recent survey from the Association for Clinical Oncology (ASCO). Oncologists indicated that prior authorization delays necessary care, worsens cancer care outcomes, and diverts clinicians from caring for their patients.
Nearly all survey participants report a patient has experienced harm because of prior authorization processes, including significant impacts on patient health such as disease progression (80%) and loss of life (36%). The most widely cited harms to patients reported are delays in treatment (96%) and diagnostic imaging (94%); patients being forced onto a second-choice therapy (93%) or denied therapy (87%); and increased patient out-of-pocket costs (88%).
Other harms Include: disease progression, patient forced to alternate site of service, denial of genetic testing, hospitalization/emergency rooms visits, denial of supportive care, patient abandoned care, and denial of cancer screenings.
“The survey results confirm what ASCO members have been experiencing first-hand for years, which is that large numbers of patients face indefensible delays or denials of cancer care,” ASCO Board Chair Lori J. Pierce, M.D., said in a press release. “We now have a clearer picture of the extent to which those hurdles lead to poorer patient outcomes, including reports of deaths. It would be unconscionable for policymakers to leave current prior authorization requirements and their effects on people with cancer unexamined.”
ASCO surveyed members from June 27, 2022 through July 30, 2022, and received 300 responses. Most respondents identified medical oncology as their primary area of clinical practice (55%) and were comparably distributed across community/hospital-based health network/systems (35%), private practice (34%), and academic/university (29%) settings
The survey also found that, on average:
• It takes a payer five business days to respond to a prior authorization request
• A prior authorization request is escalated beyond the staff member who initiates it 34% of the time
• Prior authorizations are perceived as leading to a serious adverse event for a patient with cancer 14% of the time
• Prior authorizations are “significantly” delayed (by more than one business day) 42% of the time.
Additionally, nearly all respondents report experiencing burdensome administrative requirements, delayed payer responses, and a lack of clinical validity in the process.
In a position paper, ASCO officials said another burden is “peer-to-peer” communication, which is often a call between the doctor and the payer. In many cases, ASCO finds the payer representative is not an oncologist.
ASCO is recommending that payers be accountable for prior authorization efficiency and impact and suggests that the Centers for Medicaid & Medicaid Services require reporting on patient experience, timeliness of determinations, and extent of prior authorization use. In addition, ASCO suggests the practice of piecemeal authorization — requiring prior authorization for individual medically necessary services performed during an invasive procedure that has already received prior authorization — should be prohibited.
ASCO is also suggesting that legislators require PBMs to incorporate accurate formulary data and prior authorization requirements into electronic health records. “The lack of transparency in the prior authorization process makes it difficult for providers and patients to evaluate the effectiveness, potential impact, and costs of prior authorization processes,” ASCO leaders wrote.