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ASTRO survey: Prior authorization delays care, add costs


 

Nine in 10 radiation oncologists report that prior authorization for treatment is either very challenging (42%) or moderately challenging (48%), according to data from a member survey released by the American Society for Radiation Oncology (ASTRO).

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“In 2018, [prior authorization] became the most challenging issue facing radiation oncologists,” Paul Harari, MD, Jack Fowler Professor and chair of oncology at the University of Wisconsin, Madison, and chair of the ASTRO board of directors, said during a press briefing. “Prior authorization is creating multiple obstacles to cancer patient care.”

According to responses from 673 ASTRO members, 31% said seeking prior authorization has caused delays in treatment of 5 or more days, 32% said it causes delays of 4-5 days, and 30% said it causes delays of 1-3 days. Seven percent said the prior authorization requests are resolved within less than a day.

Prior authorization delays forced 32% of respondents to alter treatment plans in more than 10% of their cases, and another 31% said treatment plans were altered in 5%-10% of their cases. For 37% of the respondents, less than 5% of their treatment plans were altered because of delays in the prior authorization process.

Data on initial treatment denials show that few hold up on appeal.

“If there is evidence of large-scale inappropriate utilization or overutilization, then treatment denials should withstand scrutiny on appeal,” Vivek Kavadi, MD, a radiation oncologist with Texas Oncology and vice chair of ASTRO’s Payer Relations Subcommittee, said during the briefing. “However, that is not what we found. This raises serious questions on the justification for the denial in the first place.”

In the survey, 41% of respondents said 76%-100% of denials are overturned, 22% said 51%-75% are overturned, 17% said 26%-50% are overturned, 19% said 0-25% are overturned, and 2% said none of their appeals resulted in a prior authorization denial being overturned.

In addition, 44% of respondents said the peer-to-peer appeals processes are typically not handled by a radiation oncologist on the payer side.

“We very rarely have a case denied following peer-to-peer review or appeal,” Dr. Harari said. “However, the many hours spent by our physician providers and the delays in commencing treatment for these cancer patients can never be recovered.”

To handle the workload generated by the prior authorization process, 63% of those responding to the survey said they have hired staff specifically to handle prior authorization requests.

“In an era of value-based care, where is the value when we are increasing costs without adding clinical benefit?” Dr. Kavadi asked.

Dr. Harari called for legislation to simplify the prior authorization process and make it less burdensome, but individual proposals were not highlighted.

SOURCE: American Society for Radiation Oncology survey.

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