Respondents to a survey by the American Society for Clinical Oncology (ASCO) said prior approval delays necessary treatment, worsens cancer treatment outcomes, and discourages physicians from caring for their patients.
Nearly all survey participants report that a patient has suffered harm as a result of prior authorization processes, including significant impacts on the patient’s health, such as: B. Disease progression (80 percent) and loss of life (36 percent). The most commonly cited harms to patients are delays in treatment (96 percent) and diagnostic imaging (94 percent); Patients forced into second-line therapy (93 percent) or refused therapy (87 percent); and increased patient expenses (88 percent).
The survey received 300 responses, and most respondents identified medical oncology as their primary area of clinical practice (55 percent) and were similarly distributed across community/hospital-based health networks/systems (35 percent), private practices (34 percent), and academic/university (29 percent) attitudes. Billing workers were most frequently identified as initiators of prior authorization (31 percent).
“The survey results confirm what ASCO members have learned firsthand for years, that large numbers of patients are facing intolerable delays or denials of cancer treatment,” said ASCO Chairman of the Board Lori J. Pierce, MD, in a statement. “We now have a clearer picture of how these hurdles are driving poor patient outcomes, including deaths. It would be unscrupulous for politicians to leave current pre-approval requirements and their impact on people living with cancer unchecked.”
The survey also asked about the hurdles oncology practices face when processing prior approval requests. Nearly all respondents report burdensome administrative requirements, late responses from payers, and a lack of clinical validity in the process:
• 97 percent state that extensive documents are required to prove the necessity
• 97 percent report delays in response from insurance companies
• 96 percent report unsuccessful appeals
• 94 percent report cumbersome appeals processes
• 91 percent report a lack of clinical expertise from pre-approval reviewers
• 91 percent report a lack of clinical validity of pre-approval programs
• 91 percent report a lack of transparency in the process
“The growing concern of ASCO members about the impact of prior approval on individuals with cancer prompted us to collect and review the latest data on their experiences,” Pierce added. “In 2018, health plans and health-care provider organizations signed consensus principles for pre-approval 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 healthcare plans to implement the reforms they have 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 employee who initiated it 34 percent of the time
• Prior approvals are considered serious adverse events 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 would expand their practice if they could reallocate the resources currently used to process pre-approvals. Common themes among the answers are:
• “See more patients”
• “Expand Supportive Care Services” (ie navigation for new patients, financial advice, patient education, nutritional advice, psychosocial support)
• “Outpatient Services”
• “palliative care”
Since its inception in 2018, ASCO has supported the Improving Seniors’ Timely Access to Care Act. IT said the legislation would streamline prior approval within Medicare Advantage (MA) by creating an electronic prior approval process in MA, making MA plans accountable for the timeliness of decisions, and requiring MA plans to be accountable for the extent of their to report prior approval. The law was passed by the US House of Representatives in September 2022 and is currently under review by the Senate, where ASCO continues to lobby for its passage.