Patterns of Unnecessary Insurer Prior Authorization Denials in a Complex Surgical Oncology Practice

Merrill, Jennifer R; Flitcroft, Madelyn A; Miller, Tracy; Beichner, Brien; Clarke, Callisia N.; Maduekwe, Ugwuji N.; Wang, Tracy; Dream, Sophie; Christians, Kathleen K.; Gamblin, T. Clark; Evans, Douglas B.; Kothari, Anai N.

doi:10.1016/j.jss.2023.03.013

Cited by 2 publications

(3 citation statements)

References 15 publications

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“…These results are similar to findings in the pediatric setting, in which 99% of 137 PAs for medication were approved after clinician involvement . Even if PA rejections appropriately restrict a limited amount of non–evidence-based care, the process frequently requires additional clinician time and overcoming logistic hurdles that may impair the quality of care for many more patients by delaying timely treatment . Lifting restrictive PA practices has been associated with guideline-concordant care in other specialties …”

Section: Discussionsupporting

confidence: 73%

“…9 Even if PA rejections appropriately restrict a limited amount of non-evidence-based care, the process frequently requires additional clinician time and overcoming logistic hurdles that may impair the quality of care for many more patients by delaying timely treatment. [9][10][11] Lifting restrictive PA practices has been associated with guideline-concordant care in other specialties. 12 Efforts to create national health policy solutions that streamline PA and make the process more transparent have been a major lobbying effort of large oncology societies.…”

Section: Discussionmentioning

confidence: 99%

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The Patient Experience of Prior Authorization for Cancer Care

Chino,

Baez,

Elkins

et al. 2023

JAMA Netw Open

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ImportancePrior authorization (PA) requires clinicians and patients to navigate a complex approval pathway. Resultant delays and denials can be particularly problematic for patients with cancer, who often need urgent treatment or symptom management.ObjectiveTo investigate the patient perspective of PA for cancer-related care, including perceptions about the process, outcomes (including delays and denials), and patient administrative burden.Design, Setting, and ParticipantsThis cross-sectional, anonymous survey used a convenience sample of patients with PA experience. Participants were recruited using social media and email lists of US-based cancer advocacy organizations from July 1 to October 6, 2022.ExposurePrior authorization for any cancer-related service.Main Outcomes and MeasuresDelays to care, outcome of PA, communication, and changes in anxiety (measured on a scale of 0-100, with 0 indicating no anxiety and higher scores indicating higher levels of anxiety) and trust.ResultsOf 178 respondents (158 women [88%], 151 non-Hispanic White respondents [84%], 164 respondents [92%] &lt;65 years), 112 (63%) reported that their cancer care was approved and given as recommended, and 39 (22%) did not receive recommended care due to delays or denials. Most respondents (123 [69%]) reported a PA-related delay in care; of those with delayed care, 90 (73%) reported a delay of 2 or more weeks. Most respondents (119 [67%]) had to personally become involved in the PA process; 35 (20%) spent 11 or more hours dealing with PA issues. Overall, the PA experience was rated as bad (70 [40%]) or horrible (55 of 174 [32%]); ratings were associated with the length of delay (ρ = 0.36; P &lt; .001) and the time spent on PA (ρ = 0.42; P &lt; .001). Self-reported PA-related anxiety was higher than usual anxiety (mean [SD] score, 74.7 [20.2] vs 37.5 [22.6]; P &lt; .001) and was correlated with delay length (ρ = 0.16; P = .04), time spent on PA (ρ = 0.27; P &lt; .001), and overall PA experience (ρ = 0.34; P &lt; .001). After PA, 159 respondents (89%) trusted their insurance company less, and 148 respondents (83%) trusted the health care system less. Patient involvement in the PA process was associated with increased odds of distrusting their insurance company (β = 6.0; 95% CI, 1.9-19.2) and the health care system (β = 3.3; 95% CI, 1.4-8.1) and of having a negative experience (β = 6.6; 95% CI, 3.1-14.3).Conclusions and RelevanceThis survey-based cross-sectional study of the patient experience with PA highlights an adverse outcome of PA: 22% of patients did not receive the care recommended by their treatment team because of PA. Most respondents experienced a delay in recommended oncology care, and delays were associated with increased anxiety, a negative perception of the PA process, and patient administrative burden.

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Section: Discussionsupporting

confidence: 73%

Section: Discussionmentioning

confidence: 99%

The Patient Experience of Prior Authorization for Cancer Care

Chino,

Baez,

Elkins

et al. 2023

JAMA Netw Open

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“…The largest bottleneck to initiating infusion identified were waiting for insurer response, which takes up to 2 weeks at times. The literature has shown that prior authorizations delay patient care, can lead to higher glucocorticoid exposure in patients awaiting an infusion for a rheumatologic condition, and lead to wasted physician time [ 23 , 24 , 25 , 26 , 27 , 28 , 29 ]. Prior authorizations for the medical benefit are still largely manual and not automated and electronic as pharmacy benefit authorizations have been.…”

Section: Discussionmentioning

confidence: 99%

Navigating Access and Optimizing Medication Infusions in an Academic Medical Center: A Quality Improvement Study

Jusufi,

Boivin

2023

Pharmacy

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(1) Background: The rising prices of medical infusions have resulted in the increased utilization of policies for payors to manage costs. These policies can be disruptive to the continuity of care, and health systems should develop a systematic strategy to address market changes and prevent patient leakage. (2) Methods: A quality improvement study was conducted by an interdisciplinary workstream to assess the current state of infusion services in an academic medical center in the Midwest and to provide recommendations for immediate access improvement and long-term system planning. An organizational assessment of the value stream was completed, which analyzed the available infusion capacity, billing strategy, patient mix/volumes, payor mix, staffing levels, and current policies. The interventions implemented after developing the infusion system strategy were triaging patients to the appropriate site of care to increase infusion capacity and eliminating paper orders in one of the health system’s Infusion Centers. (3) Results: Patients receiving medical infusions for oncologic conditions warrant unique considerations in evaluating the Infusion Center’s efficiency due to the infusion regimen’s length, complexity, and tolerability. The management of the payor site of care also poses a challenge for health systems to triage patients effectively without fragmenting care. (4) Conclusions: An organizational strategy around infusion services must include broad stakeholder representation to address the clinical, operational, and financial challenges to provide timely care to patients.

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Patterns of Unnecessary Insurer Prior Authorization Denials in a Complex Surgical Oncology Practice

Cited by 2 publications

References 15 publications

The Patient Experience of Prior Authorization for Cancer Care

The Patient Experience of Prior Authorization for Cancer Care

Navigating Access and Optimizing Medication Infusions in an Academic Medical Center: A Quality Improvement Study

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