Study: Prior authorization practices cause unnecessary delays and interference in care decisions for cancer patients

Reviewed by James Ives, M.Psych. (Editor)Apr 26 2019

Restrictive prior authorization practices cause unnecessary delays and interference in care decisions for cancer patients, according to a new survey of nearly 700 radiation oncologists -- physicians who treat cancer patients using radiation-- released today by the American Society for Radiation Oncology (ASTRO).

Nearly all radiation oncologists (93%) said that their patients are delayed from life-saving treatments, and a third (31%) said the average delay lasts longer than five days - a full week of standard radiation treatments. These delays cause added stress and anxiety to patients already concerned about their health, and they are cause for alarm given research linking each week of delay in starting cancer therapy with a 1.2% to 3.2% increased risk of death.

In addition to prevalent treatment delays, the ASTRO physician survey illuminates other ways prior authorization negatively impacts patient outcomes and takes physicians away from caring for their patients:

• More than 7 in 10 radiation oncologists (73%) said their patients regularly express concern to them about the delay caused by prior authorization.
• More than 3 in 10 radiation oncologists (32%) have been forced to use a different therapy for a substantial number of their patients (>10%) due to prior authorizations delays.

Unnecessary Delay Tactics

• Nearly two-thirds of radiation oncologists (62%) said most denials they receive from prior authorization review are overturned on appeal.
• Radiation oncology benefit management companies (ROBMs) required 85% of radiation oncologists to generate multiple treatment plans, which require physicians and medical physicists to spend several hours developing alternatives to their recommended course of treatment.
• More than 4 in 10 respondents (44%) said their peer-reviews typically are not conducted by a licensed radiation oncologist.

Wasting Physician Time

• Nearly one in five radiation oncologists (17%) said they lose more than 10% of time that they could be caring for their patients focused instead on dealing with prior authorization issues. An additional 39% spend 5-10% of their average workday on prior authorization.
• More than 4 in 10 radiation oncologists (44%) needed prior authorization for at least half of their treatment recommendations. An additional third (37%) needed it for at least a quarter of their cases.
• Many radiation oncologists (63%) had to hire additional staff in the last year to manage the prior authorization process.

Disproportionate Impact on Patients at Community-Based Clinics

• Patients treated at community-based, private practices experience longer delays than those seen at academic centers. For example, average treatment delays lasting longer than a week were reported by 34% of private practitioners vs. 28% of academic physicians (p=0.005).
• Radiation oncologists in private practice are almost twice as likely to spend more than 10% of their day focused on prior authorization, compared to physicians at academic centers (23% vs. 13%, p=0.003)

"This survey makes clear that restrictive prior authorization practices can cause unnecessary, stressful and potentially life-threatening delays for cancer patients," said Paul Harari, MD, FASTRO, Chair of the ASTRO Board of Directors and professor and Chairman of human oncology at the University of Wisconsin-Madison. "While the system may have been designed as a path to streamline and strengthen health care, it is in fact frequently harmful to patients receiving radiation therapy. In its current form, prior authorization causes immense anxiety and wastes precious time for cancer patients."

"Radiation oncology and cancer patients have been particularly hard hit by prior authorization's unnecessary burden and interference in care decisions," said Vivek Kavadi, MD, Vice Chair of ASTRO's Payer Relations Subcommittee and a radiation oncologist at Texas Oncology. "Radiation oncologists increasingly are restricted from exercising our clinical judgment in what is in the best interest of the patient, yet we are held accountable for the outcomes of treatments where decisions have been taken out of our hands."

In the 2018 annual ASTRO member survey, radiation oncologists named prior authorization as the greatest challenge facing the field. The burden was especially prominent among private practitioners in community-based settings, where the majority of cancer patients receive care.

The findings from ASTRO's new physician survey align with recent reports from the American Medical Association (AMA), American Cancer Society Cancer Action Network (ACS CAN) and others, demonstrating the pervasiveness of prior authorization obstacles throughout the American health care system.

ASTRO recently signed onto a letter with the AMA and other medical societies calling for CMS to require Medicare Advantage plans to align their prior authorization requirements with a Consensus Statement on Improving the Prior Authorization Process authored jointly by leading provider and payer organizations.

Survey Methodology

An online survey was sent by email to all 3,882 U.S. based, practicing radiation oncologists in ASTRO's member database, and 620 physicians completed the survey online. Invitations were sent in December 2018, with one email reminder in January 2019, and the survey closed in February 2019. ASTRO staff also administered paper surveys at the ASTRO Annual Meeting in October 2018 and collected 53 responses. Findings reflect the combined total of 673 radiation oncologist responses.