Prior auth is a self-inflicted wound; is there a way out?
A few months ago, a close friend called me in a panic.
Her mother had been on an oral treatment for relapsed multiple myeloma for nearly 1 year. Originally, she had been prescribed the oral pill pomalidomide as part of her regimen, but it had caused cytopenias, constipation, and nausea even at lower doses. Now, she was tolerating her new pill, ixazomib, quite well.
Then, without so much as a letter from her insurance company, the patient’s pharmacy called to tell her that ixazomib was no longer covered without a peer-to-peer conversation given its cost.
The peer to peer left the oncology team and patient even more frustrated. After leaving the team on hold for nearly an hour, the insurance company denied the request for ixazomib. The hematologist conducting the peer-to-peer did not seem to understand why the patient had discontinued her previous medication.
Ultimately, the patient was forced to return to the old, less expensive drug. Since going back to pomalidomide, she has needed multiple dosing changes to manage the intense drug side effects.
I wish that stories like this were uncommon. I am often reminded of the ongoing challenges related to prior authorization when I see colleagues regaling the Twitterverse with their latest horror stories about an insurance company rejecting standard of care treatment or imaging. The data confirm the frequency of these experiences. Among a general cohort of physicians, the American Medical Association has reported that most practices complete 29 prior authorizations per physician every week and spend on average 14.6 hours, or nearly 2 full business days, of staff time each week on these requirements.
Given the growing burden of prior authorization, reform has now become a major policy issue at the federal and state level. Within the past year, organizations like the American Society of Clinical Oncology have released policy positions on prior authorization and are devoting sizable advocacy dollars to fight payers’ ability to enact it. Entire sections of the ASCO education book are devoted to detailing the negative effects of prior authorization, and recent ASCO-commissioned surveys have highlighted alarming statistics about how prior authorization harms patient care.
As a practicing oncologist, I welcome increased attention to the burdens of prior authorization. This attention shows that our professional organizations care about one of the largest contributors to burnout.
But as a researcher who studies systems of care, I worry that focusing our collective ire on health insurance companies is somewhat misplaced or unlikely to succeed.
Why? Because policy statements, Tweets, and legislation ignore the fact that prior authorization is a self-inflicted wound caused by decades of pharmaceutical companies, health systems, oncologists, and guideline bodies failing to factor costs of care into clinical practice.
Making cost-conscious oncology care a priority would be ideal, but it is also a tall order.
But, as costs continue to rise uncontrollably, the prior authorization system has ballooned out of control and reining in this system will be quite a challenge. Perhaps, we can look to my oncology practice at a Veterans Affairs Medical Center as a guide.
