The Increasing Burden of Prior Authorizations in the Delivery of Oncology Care in the United States
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Dr. Pennell and Dr. Nancy Lin discuss whether prior authorizations reduce overall health expenditures.

Read the related article "Increasing Burden of Prior Authorizations in the Delivery of Oncology Care in the United States)" on JOP.

Hello, and welcome back to the ASCO Journal of Oncology Practice podcast. This is Dr. Nate Pennell, medical oncologist at the Cleveland Clinic and consultant editor for the JOP. Today, we're going to talk about a topic that I think is going to resonate with just about every clinical oncologist in America-- prior authorizations. Although these have been around for longer than I've been practicing, it really seemed to me over the last couple of years that more and more claims have been denied by insurance companies, more requirements for prior authorizations, and often for things that really didn't seem like they used to need prior authorizations, such as inexpensive medications. And now, based on data from the 2017 ASCO Oncology Practice Survey, we have some hard data that isn't just my imagination. This is a real phenomenon that is putting stress on an already stressed health system. Joining me today to talk about this topic is Dr. Nancy Lin, associate professor of medicine at Harvard Medical School and director of the Metastatic Breast Cancer Program at the Dana-Farber Cancer Institute in Boston. She's going to discuss her and her co-author's editorial titled "The Increasing Burden of Prior Authorizations in the Delivery of Oncology Care in the United States." For 2018, the JOP is publishing a series of papers on the state of cancer care in America, and this is part of that series. Welcome, Nancy. Thanks for joining me. Thank you. I know probably most people listening to this are familiar with prior authorizations. But can you talk just a little bit about, what is the intended purpose of prior authorizations? And is this something that ever made sense before the current craziness? Sure. Before I start, I would just like to acknowledge my co-authors on this editorial, Harvey Bichkoff, the CEO of Marin Cancer Care, and Dr. Michael Hassett, a medical oncologist at Dana-Farber. So together, we run the spectrum between academic oncologists, community practices, as well as Dr. Hassett has an interest in health policy-- so kind of running the gamut of interests here. You know, I think we can all agree that the cost of cancer care continues to increase-- I don't think that's a controversy at all-- and that continuation along this trajectory is not sustainable in the long term. So insurers, whether they are public or private, are struggling to keep premiums down while keeping up with all the new advances in diagnostics and treatments, and many of these are quite expensive. So, you think prior authorizations came out of this, which is that an attempt to try to maintain some cost containment in a way that, at least at the outset, the hope was that this would be in a fashion that would lead to the use of treatments in a medically indicated fashion and reduce the use of non-indicated treatments. That sort of makes sense, doesn't it? If people are doing things that don't have a lot of data behind them or are using the most trendy, expensive test or medication, it might actually make sense to have some control to make sure that they're following some reasonable practice or guideline. Yeah, I don't think that what is most upsetting oncologists, or oncology nurses, or front-line staff is denial of unproven or unuseful treatments. I think it's really the many and what seems to be increasing hoops that one needs to jump through in order to get testing or treatments that are really the right thing to do for patients that are really well within the standard of care. So while the PA system might have started with good intentions, I think as it is often currently constituted-- I don't want to lump all the systems together in one. But I think it contributes in a way to sort of a siege mentality. So I think if you talk to any practicing oncologist, you will hear stories of the kinds of struggles they have had getting very standard treatments approved in a timely fashion. And while in the short term, most of us make these heroic efforts to get things approved, I think that process really as set up is really counterproductive in terms of the long-term health of our health care system. So at the institution I work with at Dana-Farber, we tried to actually do a project where we quantified some of these kind of gestalt feelings. And so what we did is we actually looked at all prior authorizations for outpatient medications originating from the breast medical oncology practice over a six-month period of time. And we focused only on outpatient medication. So we're not talking about scan authorizations or IV chemotherapy but just outpatient oral medications, whether antineoplastic or not. And we found that we had to process over 300 PAs over a six-month period of time and that 97% of the PAs that were requested were approved on the very first try. We went back, and we coded whether the medications were being prescribed in accordance to NCCN guidelines. And yes, most of the time they were. And strikingly, we actually found that 15% of our PA requests were for generic medicines, like tamoxifen, aromatase inhibitors. These are medicines where there's just absolutely no debate about the efficacy or importance of the treatments. They've been around forever-- maybe not forever, but for many, many years. They're available in generic form. They're inexpensive. And then seemingly random treatments, no matter how much we appealed, we couldn't get through the PA process. And this includes a scopolamine patch for refractory chemotherapy-induced nausea or Lupron for the purpose of ovarian suppression. And I think that when clinicians deal with this on a daily basis, they see that almost 98% of their prior auths go through the first time, that you get these sort of bizarre requests for all sorts of paperwork for tamoxifen, for goodness sakes. It really gives a sense of being besieged by paperwork and process and not really being able to see a clear benefit of the PA system. And I think that really is what contributes to this burnout and the sense that the prior authorization process is broken. And it's not just your colleagues in Boston. I know, certainly, I've had that sensation here. But now we have some national data suggesting this is a problem being felt everywhere. I know that the most recent ASCO practice census, and maybe you could give us a little background on what that is, seems to show that this is a burden everywhere. ASCO actually conducted an oncology practice survey. So they've surveyed about 395 practices in 2017. This actually represented about almost 60% of the US hematology-oncology workforce. So was is a pretty big survey. There were 7,200-or-so respondents. And what was found, the key point was that payer pressures were actually the most important pressure that was felt by practices. And this was felt across all types of practices-- academic, physician-owned, rural, urban-- and that prior authorizations were actually the most commonly cited pain point, and they were cited by 78% of the respondents. So this is really something that people are feeling, truly, on a daily basis. And this is not limited just to oncology. There was a related survey by the American Medical Association. This covered not only medical oncology but primary care and other specialties and, basically, found very similar findings. Prior authorizations are a huge burden on practices. In fact, in the AMA survey, 90% of practices reported delays in care because of PAs. Almost 80% abandoned treatment plans at least some of the time because the PA is too burdensome. So these are things that have direct effects on patients. Oh, absolutely. And I think what was striking to me about the practice censuses, you may think this has always been a major issue, but this is a real change in the most recent year's survey. It was, I think, the third or fourth top concern of practices until this survey where, suddenly, it's now far and away the top burden on practices. And there is also some data I see here looking at quantifying the amount of time that it's taking staff and money, that practices are having to invest in trying to work around this pretty significant burden. There are some studies that suggest that US practices spend nearly four times as much money interacting with payers than do practices, for example, in Canada, which has obviously a very different health care model. In some studies, the costs have been estimated somewhere in the $80,000 to $90,000 per 1.0 full-time FTE physician per year just to deal with prior authorization. And in the ASCO survey, the 2017 survey, the [? hema ?] practices that were surveyed reported a requirement for an average of 6.1 FTE staff to manage prior authorization. So that's a huge burden. And I think what's important is that, more importantly than sort of the-- obviously, there's a bottom line to practices. You have to pay for these FTE. But the reality is that leaves practices to have to make decisions about how they're going to allocate their money, right? So how much are you going to support a social worker, a program nurse, a practice coordinator? How much are you going to support all of the staff required for PAs? And what proportion of the front-line physician staff, nurse practitioner staff, PA staff will be spent during office hours-- because, often, that's when one needs to do these-- interacting with payers versus providing direct patient care? So I think that this doesn't all happen in a vacuum, and that's also very important. And when you spend money in one place, you're making trade-offs in other places. Oh, absolutely. It's something that no one can ignore now. Do you know, is their actual data showing that all of these denials and prior auths, does that actually save money in health care? You know, there's not a lot of information specifically looking at oncology. That's really looking at the global picture. Because if you think about it, if you don't pay for an antiemetic, you might save money on the antiemetic, but the person may end up in the hospital with need for IV fluids. And so I haven't seen very large kind of studies that are comprehensive in that way to look at the full cost of cancer care with and without various types of prior authorization processes. That has been done in some other disease types. And in those disease types, there have been sort of mixed data as far as whether there are differences in the overall costs, for example, in the mental health area where requirements by insurers to switch from one antidepressant to another may then lead to a, for example, psychiatric hospitalization. So there, there's been a little bit more study for that. And it does seem, at least in some studies, that the overall cost of care may go up. That's not been seen in all studies. I'm not aware of really well-done studies in oncology-- they may be out there, I'm just not aware of them-- looking at the sort of overall picture, which, I think, is what we worry about. And we also worry about the other part-- is that what we can't really measure is what happens to the vulnerable patient who goes to a practice that just isn't as well resourced, and we just can't get or the practice just can't get something through that's really medically indicated, and the patient has a adverse oncology outcome as a result. And that's not really something that we, at least to date, have been able to really appropriately measure in terms of what potential impacts might be of not only prior authorizations but all the sort of different types of barriers that are present to affect care of vulnerable populations. To some extent, you have to conclude that it must be saving at least the insurance companies some money since it seems like they're doing it more and more. And that almost has to be driven by a certain percentage of claims that are people just sort of drop it because they don't want to go through all of the time that it takes to do that. That certainly doesn't seem like a very good system for patient care. I know, certainly, when I'm called to do a peer-to-peer, I always have a moment where I sort of put my head in my hands and wonder how badly I really want to do this. But obviously, if it matters, you have to push it through. And as you pointed out, when you finally get to the peer-to-peer, almost always they approve reasonable requests based on the exact same information they had when you submitted it the first time. It's not like you had to give some special, secret information to the reviewer to get it approved. That's exactly right. And I think the arbitrariness of the program or the process is part of what oncologists are responding to, those sort of lack of transparency, the sense that one could easily talk to a computer and just punch in the key for the response and get the same results. I mean, I think there is this anecdotal sense of that. And how much of that is true it's hard to know without a definitive study. But I think that is a sense that people have out in the front lines, and that's part of the frustration. Yeah. Well, so you state unequivocally that the system is broken. And I'm going to go out on a limb and say that I think you may be on to something. So what can we do? Or what are some possible solutions to this? So, I mean, I think we can all agree that a shared goal is to deliver timely, high-quality care to patients with cancer. And I really emphasize both the timely part and the high-quality part because they really go hand in hand. And so whatever we do to try to constrain costs, we really want to make sure that we're not affecting the timeliness and the quality of the care that we provide to patients with cancer. We make a number of recommendations in our editorial. But I think one key point is that we believe there is a role for some cost-containment strategies from payers. I mean, we recognize the need for it. But we think that payer-based coverage guidelines, prior authorizations, whatever sort of mechanism is there really should be the exception rather than the rule. And when they are in place, they should reflect the best and most up-to-date evidence. We shouldn't be arguing for something that was approved three years ago. And I don't know that it's really the goal or the role of insurers to micromanage every aspect of a patient's cancer care. And so I think some possibilities, like insurers have these really large [? beta ?] databases, so trying to understand and focus on which expensive medications are frequently not used according to guidelines, having two-way conversations with oncology and patient advocacy organizations in areas of controversy to try to come up to some consensus of where these somewhat more soft indications might be covered, demonstration projects to look at alternatives to prior authorizations. And I think all of these would be welcomed by the oncology community. I don't think the oncology community is unaware or doesn't care about this big elephant in the room, which is the high cost, right? But I think the pushback is really just the implementation in a way that just doesn't feel like it-- it feels like it's actually getting us away from timely, high-quality care. I think that's where the dissatisfaction comes from. And when prior authorizations, or pathways, or whatever cost-containment tool was implemented, I think listening to the oncology community is really important. So are there processes that can be simplified so that you can achieve similar results with less pain? Are there ways to make the processes or forms more uniform? So between the myriad of insurers that every provider deals with on a daily basis, every form is different. Every check box is different. Everything is different. It's a pathway. If there are pathways, you don't want to be navigating 20 different pathways, and the person on one insurance gets one chemotherapy in the third line. Maybe another on the other insurance gets this. I mean, it's just this is-- you don't want that to be how we practice medicine. And when PAs are denied, I think we want to have a streamlined appeal process. I mean, we want to ensure that the person on the other end is qualified as a peer reviewer-- which, I think, there is a sense that that's not always the case-- and also empowered to use their clinical judgment. So even when there is a clearly qualified peer reviewer, sometimes they just don't have the latitude to make clinical judgments. They're constrained in internal ways. And so I think that also gives the sense that the patient isn't the priority. And I think we just can't forget, right, the patient is the priority. Yeah, I mean, I think giving everyone the benefit of the doubt here, I think everyone's goal is to deliver the best value care, the best quality of care to the patients, and to try to keep in mind the incredible problem of the rising costs of care. And the insurance companies have been placed in a difficult position where they really have had to take something into their own hands, which means we need to get everyone to the table to try to solve this. All right, well, thanks so much for joining us. Thank you for inviting me. And I also want to thank all of you out there who joined us for the podcast. The full text of the paper is available at ascopubs.org/journal/jop, published online in August 2018. This is Dr. Nate Pennell for the Journal of Oncology Practice signing off.