Have a Prior Auth Problem? Introducing ‘Gatekeepers of Care’

Health insurance exists to protect people, providing access to routine or potentially lifesaving care without breaking the bank.

However, having insurance does not necessarily guarantee access or affordability.

People may, for instance, enroll in narrow health plans that leave them underinsured and unable to afford care. Step therapy rules may allow companies, not doctors, to make decisions about treatment pathways. And prior authorization requirements can put decisions about whether patients receive care at all in the hands of health insurers.

In recent years, prior authorization has become the poster child for barriers and delays in care. In a 2021 survey from the American Medical Association, almost all physicians involved said prior authorization delayed access to necessary care. Similarly, in a recent Medscape poll, participants said insurers denied up to 60% of their prior authorization requests, and most noted that these denials delayed treatment and put patients’ health at risk.

This process can be particularly burdensome in oncology, where many patients require time-sensitive and costly care. A 2022 analysis from Cardinal Health revealed that almost 90% of oncologists found prior authorization to be a significant barrier to prescribing new medications, and 80% said the process negatively affected patient outcomes. In some instances, prior authorization delays may lead to patient death.

Fundamentally, “the most important thing is the patient is getting a treatment they need and that is consistent with established scientific guidelines,” Vivek Kavadi, MD, a radiation oncologist at Texas Oncology in Sugar Land, Texas. However, “what has happened now is that many insurance companies have taken it upon themselves to dictate care.”

But while it’s easy to say ‘how dare these insurance companies,’ the rise of prior authorization largely reflects rising healthcare costs, Michael Anne Kyle, PhD, RN, a postdoctoral fellow in the Department of Health Care Policy at Harvard Medical School and the Dana-Farber Cancer Institute in Boston, explained.

The initial aim of prior authorization was to limit low-value care and “help steer people into evidence-based treatment,” said Kyle. Especially in oncology, “drugs are becoming increasingly expensive and are being brought to market through accelerated approval pathways that require less rigorous evidence of efficacy. Prior authorization became one of the only tools we have to put guardrails on spending on low-value care,” she said.

In a 2017 survey, physicians reported that about 15%–30% of medical care was unnecessary, including 22% of prescription medications, 25% of tests, and 11% of procedures. And a 2019 analysis estimated that this type of overtreatment or low-value care can lead to as much as $101 billion in wasteful spending in the United States.

However, instead of agreeing on a definition of value at a societal level, “we’ve punted these decisions down to the point of care,” Kyle said. “Going prescription by prescription is messy and inefficient. Making coverage decisions is difficult but necessary work — we’ve delegated this responsibility to insurers, and we’ve ended up with a byzantine bureaucracy around prior authorization that is inconsistent and frustrating.”

The scope of prior authorization has become expansive. A 2021 analysis estimated that, under Medicare Advantage, 97% of radiation oncology services and almost 90% of oncology services now require prior authorization.

To handle the growing administrative burden, “a lot of physician practices have hired staff to focus on prior authorization,” said Kelly Anderson, PhD, MPP, assistant professor in the Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora.

Alongside volume lies complexity. There is no standard process for prior authorization. Every health insurer has different requirements for what care needs prior authorization, how requests are submitted and appealed, and how long each leg takes. Even within a single company, prior authorization policies may differ by health plan or state, Anderson explained.

And the process for reviewing these requests is far from foolproof. A 2018 investigation by the Office of Inspector General found that the Centers for Medicare & Medicaid Services (CMS) cited more than half of audited Medicare Advantage contracts for inappropriately denying prior authorization requests. And often the denial letters did not contain adequate information about why the request was denied or how the denial can be appealed.

Recent federal- and state-level efforts may help curb some of these burdens. For instance, on December 13, CMS outlined a set of changes to the prior authorization process that could make it more streamlined and standardized. The proposed rule would require payers to make information about prior authorization requests and decisions for items and services available to patients no later than 1 business day after the payer receives the request. In addition, when a request is denied, the payer must provide a specific reason for the denial. However, the proposed rule excludes drugs.

Anderson, lead author of a Viewpoint article in JAMA this past October, highlighted reforms she’d like to see applied to all care. Most notably, forms and processes would be standardized across plans and all prior authorization requests and appeals would happen electronically, making requests easier to expedite. Insurers would also have time-bounded requirements for initial requests and appeals and would provide a clear reason for a denial, distinguishing those resulting from easy-to-correct clerical errors, such as missing information, vs substantive appeals.

In addition, CMS could monitor the number of denials an insurer issues each year, identifying and auditing outlier plans that may be deemed as inappropriately denying care.

While there are instances where prior authorization can be in the best interest of the patient — for example, by identifying a lower cost but equally effective treatment, “streamlining the process can maintain these benefits while lowering the burden on patients and clinicians,” Anderson said.

“One of the biggest challenges we see in oncology is how time-sensitive prior authorization requests are,” she added. “Delays of weeks, even days, for people with cancer can adversely affect their care and outcomes.”

In a new regular series, Gatekeepers of Care, Medscape will explore the challenges oncologists face navigating insurance company requirements and accessing cancer care.  

Read our first column here. Please email [email protected] to share experiences with prior authorization or other challenges receiving care.

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