Prior authorization is harming individuals with cancer, according to new survey results from ASCO. The survey found that prior authorization delays necessary care, worsens cancer care outcomes, and diverts clinicians from caring for their patients.
Nearly all survey participants reported a patient experiencing harm because of prior authorization processes, including significant impacts on patient health such as disease progression (80%) and loss of life (36%). The most widely cited harms to patients reported are delays in treatment (96%) and diagnostic imaging (94%); patients being forced onto a second-choice therapy (93%) or denied therapy (87%); and increased patient out-of-pocket costs (88%).
“The survey results confirm what ASCO members have been experiencing first-hand for years, which is that large numbers of patients face indefensible delays or denials of cancer care,” said ASCO Board Chair Lori J. Pierce, MD, FASTRO, FASCO. “We now have a clearer picture of the extent to which those hurdles lead to poorer patient outcomes, including reports of deaths. It would be unconscionable for policymakers to leave current prior authorization requirements and their effects on people with cancer unexamined.”
The survey also asked about the hurdles oncology practices face while processing prior authorization requests. Nearly all respondents reported experiencing burdensome administrative requirements, delayed payer responses, and a lack of clinical validity in the process:
- 97% reported onerous documentation needed to demonstrate necessity.
- 97% reported response delays from insurance companies.
- 96% reported unsuccessful appeals.
- 94% reported obstructive appeal processes.
- 91% reported a lack of clinical expertise by prior authorization reviewers.
- 91% reported a lack of clinical validity of prior authorization programs.
- 91% reported a lack of transparency in the process.
“ASCO members’ growing concerns about the impact of prior authorization on individuals with cancer led us to collect and examine the latest data on their experiences,” said Dr. Pierce. “In 2018, health plans and health provider organizations signed on to consensus principles for prior authorization reforms, but the plans have not implemented them. ASCO will continue to advocate for policies that protect patients and ensure access to the timely care they need, and we call on health plans to take up the reforms they agreed to.”
The survey also found that, on average:
- It takes a payer 5 business days to respond to a prior authorization request.
- A prior authorization request is escalated beyond the staff member who initiates it 34% of the time.
- Prior authorizations are perceived as leading to a serious adverse event for a patient with cancer 14% of the time.
- Prior authorizations are “significantly” delayed (by more than 1 business day) 42% of the time.
Respondents were asked what patient services their practice would expand if they could reallocate the resources currently used for processing prior authorizations. Common themes among the responses include:
- “See more patients”
- “Expand supportive care services” (ie, new patient navigation, financial counseling, patient education, nutrition counseling, psychosocial support)
- “Outpatient services”
- “Palliative care”
- “Research.”
This underscores the real and unsustainable cost of the current structure of prior authorization and the price—in progress and care—all Americans are paying for it.
About the Survey and Next Steps
The survey, which was widely distributed to U.S. ASCO members, was in the field from June 27 through July 30, 2022, and received 300 responses. Most respondents identified medical oncology as their primary area of clinical practice (55%) and were comparably distributed across community/hospital-based health network/systems (35%), private practice (34%), and academic/university (29%) settings. Billing staff were most frequently identified as initiating prior authorization (31%).
ASCO included its survey data in a new position statement on prior authorization. The statement details ASCO members’ concerns regarding prior authorization and makes recommendations for state and federal policymakers, regulatory agencies, and other stakeholder groups to strengthen oversight around prior authorization practices.
Since its introduction in 2018, ASCO has supported the Improving Seniors’ Timely Access to Care Act. The legislation would streamline prior authorization within Medicare Advantage (MA) by creating an electronic prior authorization process in MA, holding MA plans accountable for the timeliness of determinations, and requiring MA plans to report on the extent of their prior authorization use. The bill passed the U.S. House of Representatives in September 2022 and is currently being considered by the Senate, where ASCO continues to advocate for its passage.
Visit asco.org/priorauth for more information.
