Breast oncologist Debra Patt, MD, PhD, was getting off an airplane when an insurance company’s prior authorization peer-to-peer (P2P) specialist called her to talk about the treatment regimen she prescribed for a patient that had been denied by the insurance company four weeks earlier.
After a brief discussion, the other physician decided the course of treatment originally prescribed by Dr. Patt was reasonable and gave her authorization to prescribe it. The problem was that it came too late.
When prior authorization for the original treatment was denied, Dr. Patt was told that it could take up to six weeks for a P2P consult and that the insurance company couldn’t tell her in advance when the other doctor would call.
Her patient, a 40-year-old woman with rapidly growing metastatic breast cancer, couldn’t wait.
“Six weeks was an unacceptable amount of time,” said Dr. Patt, who practices in Austin, Texas. “She would clinically deteriorate in that time.”
Dr. Patt thought her patient was a good candidate for a promising new regimen known as MonarcHER.
When the insurance company denied that course of treatment, she prescribed a more standard chemotherapy regime, which—because of related toxicities—made it impossible for her patient to keep working. So by delaying her care, the insurance company dramatically worsened the woman’s quality of life.
“It's incredibly frustrating for her—and for patients more broadly—because they feel like they don't have any control over what's going to happen, what their journey is going to look like,” said Dr. Patt, a partner and the executive vice president of with Texas Oncology, a private medical practice with 220 locations that sees 70,000 new cancer patients a year.
Along with 520 physicians, the group has about 175 people on staff whose sole job is managing prior authorization requests. In fact, Dr. Patt’s own team has two people assigned to that task—with one handling imaging prior auth requests and another to shepherd therapy-related prior authorizations.
“It's frustrating and, honestly demoralizing as a doctor,” added Dr. Patt, who took part in a panel discussion on fixing prior authorization at the 2023 AMA State Advocacy Summit. “I've been a breast medical oncologist for 16 years. I'm a national principal investigator on trials. I know a lot of data about breast cancer. So for it to be so difficult for me to get my patients what they need is really quite challenging.”
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.
Building the case for reform
Practicing in Texas, Dr. Patt had hoped that a landmark “gold card” law enacted there would have a swift effect to help lessen the maddening care impact of prior authorization.
Serving as vice president of the Community Oncology Alliance, immediate past president of the Texas Society of Clinical Oncology and a past chair of the Texas Medical Association (TMA) Council on Legislation, Dr. Patt testified before the Texas Legislature in 2021 in support of the gold-carding law.
The Texas law, which took effect last October, was intended to exempt physicians from burdensome prior authorizations if they earned approvals on at least 90% of prior authorization requests for a given service or medication.
But implementation of the law by the Texas Department of Insurance has been problematic, and the TMA reports a lack of enforcement and liberties taken in the rulemaking that create barriers to entry to qualify for the exemption.
“There's been a lot of excitement” about the gold-carding approach in other states and a bill proposed in Congress, Dr. Patt noted. But, she added, “the devil, as always in health care policy, is in the details. ... Payers were supposed to distribute to doctors' guidelines about what they were gold carded for. That has not happened.”
The TMA is looking for regulatory and legislative fixes to resolve these issues. Dr. Patt recommended consulting with the TMA about its experience on working with the state insurance department to anticipate what could happen in the rulemaking stage after a bill is passed and signed into law.
What has to change
The AMA offers model prior-authorization legislation (PDF) and reform principles (PDF) to fix prior authorization. Reform bills need to address several issues such timeliness, limits on the scope of prior authorization and that P2P consults must be with a physician of the same or similar specialty, Dr. Patt said.
While the physician Dr. Patt spoke with on the phone at the airport was not a breast cancer specialist, at least that person was an oncologist.
“I have been in the situation where I've been managing prior authorization for the very specific treatment of a breast cancer patient with a retired obstetrician,” she recalled. “They said things to me that are just known by any oncologist to be factually untrue.”