Cancer patients’ verdict on prior authorization? It’s horrible

Tanya Albert Henry , Contributing News Writer

Patients, too, say prior authorization is “horrible.”

Among cancer patients, the payer cost-control practice is causing anxiety, delaying their care and eroding their trust in the health care system as a whole, according to a study published in JAMA Network Open.

Fixing prior authorization

Prior authorization is costly, inefficient and responsible for patient care delays. The AMA stands up to insurance companies to eliminate care delays, patient harm and practice hassles.

More than 30% of patients with cancer who faced prior authorization in the course of their care called the experience “horrible” and another 40% rated it as “bad,” according to the findings from a cross-sectional survey of 178 such patients.

It is not surprising that patients felt this way. Among the patients surveyed, 22% reported that they did not get the care their physician recommended because of delays or denials. In the worst-case scenarios, those denials or delays can lead to patients dying, like the story that one breast oncologist shared during an episode of “AMA Update” earlier this year.

Beyond not getting recommended care, the JAMA Network Open study also found that among those surveyed:

  • 69% reported that prior authorization resulted in a delay in care. Among those patients, 73% reported that the delay was two weeks or longer.
  • 67% of patients had to personally become involved in the prior authorization process, with 20% spending 11 or more hours dealing with prior authorization issues.

In turn, those experiences resulted in:

  • Patients self-reporting that prior authorization-related anxiety was higher than usual anxiety.
  • 18% trusting their cancer team less.
  • 89% trusting their insurance company less.
  • 83% trusting the health care system less.

“It’s causing delays. It’s harming patients not just by increasing their anxiety, but also by stealing their time. But it’s also eroding trust. That idea of trust being so essential in health care, it’s underappreciated,” said the study’s lead author, Fumiko Chino, MD, a radiation oncologist at Memorial Sloan Kettering Cancer Center.

“You can derail the whole health care system if there is a lack of trust in what we are recommending. People won’t get COVID vaccines; they won’t get cancer screenings,” she said.

“Patients have some real harms from these policies and it’s delaying their care,” Dr. Chino added. “Outside of the delay, the whole process is very anxiety-provoking, which itself has negative, downstream implications for people with cancer. It’s worsening the experience of cancer treatments—and cancer treatments are horrible enough as it is.”

Fixing prior authorization is a critical component of the AMA Recovery Plan for America’s Physicians.

Prior authorization is overused, and existing processes present significant administrative and clinical concerns. Find out how the AMA is tackling prior authorization with research, practice resources and reform resources.

The data behind the sad stories

While payers claim that prior authorization requirements are used for cost and quality control, a vast majority of physicians report that the protocols lead to unnecessary waste and avoidable patient harm.

One-third of the 1,001 physicians surveyed (PDF) by the AMA reported that prior authorization has led to a serious adverse event for a patient in their care. Studies such as the AMA’s that examine prior authorization from the physician’s perspective are valuable, but this is believed to be the first to ask oncology patients about their experience with prior authorization.

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“There are people in state and federal government that are trying to put forward policies that would improve transparency within prior authorization and improve the efficiency of the process, but people in legislative offices told me they are stymied by the fact that there is not great data,” Dr. Chino said. “Without the measurable harms that we are showing, it’s hard to make a case and people can say, ‘Oh, that’s just a sad story, it’s not what is happening to most people.’”

The powerful House Ways and Means Committee has advanced provisions that would help bring badly needed reforms to the prior authorization process within Medicare Advantage, and the Centers for Medicare & Medicaid Services is being pressed to finalize plans to streamline prior authorization in the program.

Visit AMA Advocacy in Action to find out what’s at stake in fixing prior authorization and other advocacy priorities the AMA is actively working on.