Drug costs and requirements for prior authorization of treatment plans pose barriers to cancer treatment and can potentially affect outcomes for many patients, according to two studies that will be presented at the ASCO Quality Care Symposium.
The studies respectively examine how the high out-of-pocket costs for oral cancer therapy impact overall survival rates (Abstract 3), and demonstrate how a successful collaboration between a health system and a commercial payor can streamline the prior authorization process and get patients into treatment more quickly (Abstract 9).
Out-of-Pocket Costs for Oral Therapies
Researchers from Fred Hutchinson Cancer Research Center found that the out-of-pocket cost of oral tyrosine kinase inhibitors were not only linked to a lower number of these prescriptions and shorter duration of therapy, but also were associated with poorer survival in patients with advanced non–small cell lung cancer (NSCLC) with certain tumor genomic mutations.
The study included 106 patients with stage IV NSCLC identified from the Washington State Surveillance, Epidemiology and End Results registry. These patients had mutations of epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) genes. Data from the registry were paired with claims data. To be included, patients had to have at least one prescription for an oral tyrosine kinase inhibitor. The researchers calculated median out-of-pocket tyrosine kinase inhibitor costs for the first 3 months of therapy. Patients were categorized into quartiles based on these costs.
Based on a multivariate analysis, the researchers found that the quarter of patients in Washington state with the highest median out-of-pocket costs were more than twice as likely to die after 3 months of tyrosine kinase inhibitor initiation (adjusted hazard ratio = 2.31; P = .003) compared with all other patients in the study.
“Patients paying the highest out-of-pocket costs for tyrosine kinase inhibitors have a greater risk of death,” said lead author Bernardo H.L. Goulart, MD, MS, medical oncologist and outcomes researcher at Fred Hutchinson. “If we can confirm the results with a larger nationwide sample, the findings help to make the case for a review of Medicare coverage for these effective medications.”
The results will need to be confirmed in a larger nationally representative sample before firm conclusions can be drawn.
Commercial Payor Collaboration on Prior Authorization
Researchers with the Seattle Cancer Care Alliance found that the majority of prior authorizations (94.8%) for imaging studies were approved instantly or after the provision of additional information. The findings led the Alliance to partner with a large regional commercial payor to eliminate the need for prior authorizations.
“While prior authorizations are intended to ensure medical necessity, these additional requirements can add to administrative burden,” said lead author Mallika Sharma, MPH, a quality and value analyst at Seattle Cancer Care Alliance. “In some cases, the process can even cause significant delays for patients, increasing their anxiety and diminishing quality of life.”
After reviewing imaging requests, the researchers found that 94.8% of prior authorizations were approved instantly or after providing more documentation, 2.15% of requests were approved after a peer-to-peer review, and only 3% of prior authorizations did not meet medically necessary criteria.
Given these findings, the Alliance worked with a large commercial payor to eliminate prior authorizations for all imaging requests (excluding positron emission tomography [PET] and PET/computerized tomography). As part of this agreement, all ordering clinicians were required to complete training on Imaging Appropriate Use Criteria from the National Comprehensive Cancer Network®. Internal audits showed that the Alliance achieved 100% compliance.
“[The Alliance] uses an in-house tool to support clinical decision-making,” said principal investigator Tracy Wong, MBA. “However, most electronic health records have the capability to embed clinical decision support that aligns with payers’ medical coverage policies, making this a relatively simple and scalable way to speed and improve care. This is what payers are asking for: the ability for providers to access the most up-to-date, evidence-based practice guidelines in real time.”
The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.