We read with interest the recent commentary by S. Monica Soni, MD, and Andrew A. Hertler, MD, FACP, on prior authorization (June 10, 2023, issue of The ASCO Post). The nuances of prior authorization in our health-care landscape are both complex and consequential. Conceived as a safeguard against potentially inappropriate treatments and financial missteps, the evolution of prior authorization has brought unintended effects that demand our attention, failing to achieve the original goals and causing havoc on patient care and physician workflows.
We are all aware of the fallout when treatments get caught in the prior authorization web. Patients face out-of-pocket costs, anxiety, and treatment delays—each day potentially catalyzing disease progression. The system, too, pays a cost, and so do we, as clinicians. Physician burnout, fueled by administrative burden, is an undeniable reality.
A disconcerting layer is the possible exacerbation of care disparities. A study in JCO Oncology Practice1 highlighted that Black and Hispanic patients with gynecologic cancer were more likely to have their prior authorization requests denied than White patients—a trend contradicting our commitment to equitable care.
We agree that the rapid pace of advancements in fields like oncology creates a complex environment. Is prior authorization the right solution to navigate this challenge? A 2021 ASCO report2 revealed alarming figures—96% of oncology providers have seen patients suffer because of prior authorization, facing treatment delays and second-choice therapies as well as increased costs. Can the marketplace truly afford to pay margin to parties who do not have an invested stake on the ground in the provision of patient care?
Let’s ponder alternatives and potential improvements. Practices might consider a two-sided risk alternative payment model, potentially eliminating the need for prior authorization. Involving patients and their advocates more deeply in the process could also be beneficial. If prior authorization must persist, let the reviewers be practicing hematologists or oncologists who understand the nuances of care. The appeal process, currently skewed toward the payer, calls for a major overhaul.
In essence, our shared aspiration shouldn’t merely be a functional relationship between providers and payers. It should be the unerring pursuit of the best patient outcomes. Our compass must point toward their well-being, from cure to comfort or effective palliation.
—Lucio N. Gordan, MD
President and Managing Partner
Nathan Walcker, Chief Executive Officer
Josh Eaves, Chief Development Officer
Florida Cancer Specialists & Research Institute
REFERENCES
1. Smith AJB, Mulugeta-Gordon L, Pena D, et al: Insurance and racial disparities in prior authorization in gynecologic oncology. Gynecol Oncol Rep 46:101159, 2023.
2. ASCO in Action: Nearly all oncology providers report prior authorization causing delayed care, other patient harms: ASCO survey shows negative impact of prior authorization on cancer care. Available at https://old-prod.asco.org/news-initiatives/policy-news-analysis/nearly-all-oncology-providers-report-prior-authorization. Accessed August 1, 2023.
