Treatment Delays Associated With Prior Authorization for Infusible Medications: A Cohort Study

Abstract

Objective. Prior authorizations (PAs) are commonly used by insurers as cost-containment strategies for expensive medications, including infused biologics. There is scarce data about the effect of PA requirements on patient-oriented outcomes. Methods. We included patients for whom an infusible medication was prescribed for a rheumatologic condition. The exposures of interest were a PA requirement and whether or not the PA was denied. The primary outcome was the difference in days from medication request to infusion. Secondary outcomes included the proportion of denied PAs and differences in glucocorticoid exposure following a PA request. Results. Of the 225 patients, the infusible medications of 160 (71%) required a PA. PAs were associated with a greater number of days to infusion compared to cases in which no authorization was required (median 31 days [interquartile range (IQR) 15-60 days] versus median 27 days [IQR 13-41 days]; P = 0.045), especially among the 33 patients (21%) whose PA was denied initially (median 50 days [IQR 31-76 days] versus median 27 days [IQR 13-41 days]; P < 0.001). PA denials were associated with greater prednisone-equivalent glucocorticoid exposure in the 3 months following the request than when a PA was not required (median 605 mg [IQR 0-1,575] versus median 160 mg [IQR 0-675]; P = 0.01). Twenty-seven of the 33 PA requests that were initially denied (82%) were eventually approved. Thus, 96% of all PAs were ultimately approved. Conclusion. PA requirements are associated with treatment delays and denials are associated with greater glucocorticoid exposure. Because the great majority of PA requests are ultimately approved, the value of PA requirements and their impact on patient safety should be reevaluated.

What Is the Impact of Prior Authorization on the Incidence of Pediatric Tonsillectomy?

“…In the years following implementation of PA, just 1.5% of all claims for tonsillectomy were denied approval. Our findings are similar to those of other studies that demonstrate very low denial of PA claims (<4%) for elective surgery, prescription medications, and imaging studies 13,15–17 . Furthermore, no statistically significant reduction in the incidence of tonsillectomy was discovered after implementation of PA for government plans alone, commercial plans alone, or all plan types combined.…”

“…Some studies demonstrated weeks-long delays in medication and infusions approvals, which led to increased adverse events and exposures or abandonment of the therapy entirely. 14,17,26 Although outside the scope of this study, there are concerns that PA is time-consuming and may result in additional money spent to process claims. One study evaluation PA for prescription medications in pediatric hematology and oncology noted that 20% of claims that were initially denied PA (1) did not actually need PA and were therefore approved or (2) were approved after the filing of additional paperwork or with a change in prescription.…”

Influence of Prior Authorization Requirements on Provider Clinical Decision Making

“…Frequently, PA-related cost restrictions create delays that result in patients abandoning prescriptions [17]. These findings have been replicated across a number of specialties including rheumatology, psychiatry, primary care, oncology, infectious disease, and dermatology [9,11,13,14,15,16].…”

“…There is also growing evidence that the medication PA process can delay patient care and contribute to adverse patient outcomes. This has been noted in rheumatologic care with infusible treatments initially denied [13] as well as other medical specialties [9,11,14,15,16]. When surveyed, 24% of physicians noted that PA had led to a serious adverse event in one of their patients, 91% reported that PA requirements cause care delays, and 90% reported that PA delays resulted in worse patient outcomes [4].…”

A comprehensive framework for navigating patient care in systemic sclerosis: A global response to the need for improving the practice of diagnostic and preventive strategies in SSc

“…Prior Authorizations (PAs): Advocacy for streamlining PAs [96] is essential to improve patient survival and outcomes. Further, denials lead to higher insurance company costs [97], as most clinicians finally attain authorization [98]. An organized approach can expedite most procedures and medication authorizations, including an appeal, within 72 h in the US.…”