The Impact of Prior Authorization on Patients With Cancer

For physicians, prior authorization is a process that many have grown accustomed to and that nearly everyone in the medical field has an opinion on. The process of prior authorization is theoretically designed to seek approval from a health insurance provider to ensure that prescriptions, procedures, or other costs will be covered by a patient’s plan.

Unfortunately, many critical services are impacted by this process. Prior authorizations can often take more than a week, a wait time that many patients often may not have the luxury of withstanding.

Cardinal Health Specialty Solutions publishes a biannual research-based report series called Oncology Insights, which aims to analyze the views of oncologists nationwide. The most recent report, published in June, found that the vast majority of oncologists feel that prior authorizations negatively impact patient outcomes and ability to start new medications.

The responses indicate that the prior authorization process is harming both patients and practices themselves, requiring extra manpower to navigate appropriately, a problem that they believe should be addressed by new government policies.

Findings include:

• Nearly 90% of oncologists polled said prior authorization is a somewhat, moderately, or extremely significant barrier to starting new patients on medication.
• For patients whose treatment requires prior authorization, 80% of oncologists said prior authorizations have a somewhat or significant negative impact on patients.
• More than 80% of participating oncologists said they have full-time staff dedicated to managing prior authorization and benefits issues.
• More than 7 in 10 participating oncologists said they would support federal policies streamlining the prior authorization process.
• More than 9 in 10 participants said prior authorizations delay access to necessary care at least sometimes.
• Two-thirds of survey participants said pharma-sponsored programs are valuable in helping patients navigate prior authorizations and other access barriers.

Patient access to specialty medication is not a new barrier, but the surge of specialty medications coming to market combined with the rapid pipeline of precision medicines has created heightened challenges for patients and physicians.

The Oncology Insights report shows that steps such as prior authorization are not only delaying time to treatment for one-third of patients by more than 7 days, but these delays directly impact patients’ clinical outcomes. These results are especially true for more complex treatments, such as chimeric antigen receptor (CAR) T-cell therapies. In the December 2021 report, oncologists cited slow approval processes by payers as the single most challenging issue in the CAR T-cell therapy referral process.

In addition to policy changes, oncologists shared thoughts on what changes can lessen these negative outcomes. Standardized forms (31%) and technology systems that automate the process (30%) were the most popular responses for ways to reduce the challenges created by prior authorizations.

Although it is unlikely that standardized forms can fix the issue, given the complexity of the current health care reimbursement landscape, prior authorization technology solutions have been shown to decrease delays by 25%, which can help patients begin therapies sooner.¹ Improved access to that technology could lessen the need for policy changes and close the gaps in frustrating timelines for physicians.

Although pharma manufacturers are spending more than $5 billion annually on patient support programs that aim to provide more access to treatments and improve adherence,² not every oncologist is seeing the benefits in their own practice. Of oncologists polled, 28% said they felt programs had a neutral value or were not valuable in helping patients navigate prior authorizations.

In addition, 10% said “only a few” oncology therapies they prescribe have patient access programs and 7% said they were unaware of whether their therapies have patient access programs. This shows us that although dollar figures being spent on these programs are high, there is still plenty of opportunity for improved education and awareness.

For many oncologists, prior authorization technology solutions already exist that can address their needs through customizable, integrated capabilities that can help avoid delays and automate administrative tasks.

As technology continues to evolve, we must use it to decrease the negative impact of these delays on patient care.

References

1. Electronic Prior Authorization Information (n.d.) Retrieved June 27, 2022. https://www.caremark.com/wps/portal/HEALTH_PRO_PRIOR_AUTH_INFO
2. Pharmas' return on $5B spent yearly on patient support programs? Only 3% are using them: survey (2021, July 6) Retrieved June 27, 2022.https://www.fiercepharma.com/marketing/pharmas-return-5-billion-spent-yearly-patient-support-programs-only-3-use-survey#:~:text=Pharma%20companies%20spend%20more%20than,survey%20from%20Phreesia%20Life%20Sciences.