Survey Highlights Impact of Prior Authorization on Cancer Care

Nov. 23, 2022
ASCO survey respondents report delays in treatment and diagnostic imaging as well as patients being forced onto a second-choice therapy or denied therapy

Respondents to a survey by the American Society for Clinical Oncology (ASCO) said 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 percent) and loss of life (36 percent). The most widely cited harms to patients reported are delays in treatment (96 percent) and diagnostic imaging (94 percent); patients being forced onto a second-choice therapy (93 percent) or denied therapy (87 percent); and increased patient out-of-pocket costs (88 percent).

The survey drew 300 responses, and most respondents identified medical oncology as their primary area of clinical practice (55 percent) and were comparably distributed across community/hospital-based health network/systems (35 percent), private practice (34 percent), and academic/university (29 percent) settings. Billing staff were most frequently identified as initiating prior authorization (31 percent).

“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,” said ASCO Board Chair Lori J. Pierce, M.D., in a statement. “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.”

The survey also asked about the hurdles oncology practices face while processing prior authorization requests. Nearly all respondents report experiencing burdensome administrative requirements, delayed payer responses, and a lack of clinical validity in the process:

• 97 percent report onerous documentation needed to demonstrate necessity

• 97 percent report response delays from insurance companies

• 96 percent report unsuccessful appeals

• 94 percent report obstructive appeal processes

• 91 percent report a lack of clinical expertise by prior authorization reviewers

• 91 percent report a lack of clinical validity of prior authorization programs

• 91 percent report a lack of transparency in the process

“ASCO members’ growing concerns about the impact of prior authorization on individuals with cancer led us to collect and examine the latest data on their experiences,” added Pierce. “In 2018, health plans and health provider organizations signed on to consensus principles for prior authorization reforms, but the plans have not implemented them. ASCO will continue to advocate for policies that protect patients and ensure access to the timely care they need, and we call on health plans to take up the reforms they agreed to.”

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 percent of the time

• Prior authorizations are perceived as leading to a serious adverse event for a patient with cancer 14 percent of the time

• Prior authorizations are “significantly” delayed (by more than one business day) 42 percent of the time

Respondents were asked what patient services their practice would expand if they could reallocate the resources currently used for processing prior authorizations. Common themes among the responses include:

• “See more patients”

• “Expand supportive care services” (i.e., new patient navigation, financial counseling, patient education, nutrition counseling, psychosocial support)

• “Outpatient services”

• “Palliative care”

• “Research”

Since its introduction in 2018, ASCO has supported the Improving Seniors’ Timely Access to Care Act. IT said the legislation would streamline prior authorization within Medicare Advantage (MA) by creating an electronic prior authorization process in MA, holding MA plans accountable for the timeliness of determinations, and requiring MA plans to report on the extent of their prior authorization use. The bill passed the U.S. House of Representatives in September 2022 and is currently being considered by the Senate, where ASCO continues to advocate for its passage.

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