How the administrative burden of prior authorization puts patients at risk with Fumiko Chino, MD

. 11 MIN READ

AMA Update covers a range of health care topics affecting the lives of physicians, residents, medical students and patients. From private practice and health system leaders to scientists and public health officials, hear from the experts in medicine on COVID-19, medical education, advocacy issues, burnout, vaccines and more.

The very real—and potentially deadly—consequences of prior authorization on patients. Fumiko Chino, MD, a radiation oncologist, at Memorial Sloan Kettering Cancer Center, joins to break down the impact of prior authorization on cancer care patients. Dr. Chino shares harrowing stories of her own and the findings of her new study in JAMA, “The Patient Experience of Prior Authorization for Cancer Care.” AMA Chief Experience Officer Todd Unger hosts.

Speaker

  • Fumiko Chino, MD, radiation oncologist, Memorial Sloan Kettering Cancer Center

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Unger: Hello and welcome to the first AMA Update video and podcast of 2024. We're beginning the year talking about prior authorization and the very real consequences it can have for patients when it results in delayed or denied care.

Our guest today is Dr. Fumiko Chino, a radiation oncologist at Memorial Sloan Kettering Cancer Center. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Chino, thanks so much for joining us today.

Dr. Chino: Thank you for having me from New York City.

Unger: Well, you were the lead author on a study published in JAMA called the "Patient Experience of Prior Authorization for Cancer Care." We've studied the burden of prior authorization that puts on physicians, but not many studies capture the patient perspective. For the first question, why was this something that was important to study?

Dr. Chino: Most of the research that I do is really rooted in the patient experience because I think we have some good perspective on how, for example, health care costs are rising across the United States for health insurance companies. But my specific interest has always been in financial toxicity or how cost are being pushed on to patients.

And my research in prior authorization really, kind of, aligns with that, which is we know that prior authorization is awful for me as a physician. But ultimately, the person who has to kind of hold the ultimate burden of it is the patient. They're the ones who are getting denied, delayed. They're having worse outcomes related to prior authorization.

Unger: And we've seen that those kinds of delays that can really harm patient care and, in particular, with your specialty which is oncology, delays in care can be really devastating. Do you have any instances where you experienced this firsthand with your own patients that you can share with us?

Dr. Chino: Absolutely. So I'm a treating oncologist. That means I see people every single week who are receiving active cancer treatment, and I can tell you that prior authorization is a real burden for me pretty much every single week. I'll see a patient whose care has been delayed or denied by prior authorization processes, and this spans the full spectrum from radiation treatment, which is what I deliver in my clinic, but even the medications that I'll prescribe for things like pain or nausea.

I have patients who are having to ration their pain medications because their insurance will only pay for a certain number of pills. I've had patients who have had to come into the hospital. And ultimately, it ended up being more expensive for their insurance because they weren't able to get the appropriate and adequate care due to some restrictive utilization processes from prior authorization.

So absolutely it's something that I've seen my patients suffer. And unfortunately, I've seen patients die from prior authorization. I'll just put it like that. I'll be so bold.

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Unger: What do you—tell us more about that. What does that mean?

Dr. Chino: So when you think about the best care that we can provide—and I have the benefit of being at a world leading cancer center—we have every amazing technology that the last 100 years of medicine has led up to us being able to provide the precision medicine, medicine that we provide for our patients. And when we're not able to give the best care, we know that there are consequences.

So we know that, for example, for every week of delay for certain types of cancers, there are actual outcomes worsen meaning that their cancer is more likely to recur. And I've seen cancer growing on patients and wanting to start radiation so quickly to try to stop the cancer growth and having to wait tick tock for that insurance approvals.

I have the benefit of working at a cancer center that we're able to just start forward with treatment realizing that we may not be paid, but I also know that some patients being treated in the community or in centers with less resources, they're not able to just go forward without potential reimbursement. And so it's a real burden for our patients and our providers. It's leading to moral distress in the health care workforce. And again, it's leading to worse outcomes for our patients.

Unger: Dr. Chino, those are really harrowing stories. And again, back to your focus on patient experience, I'd like to talk more about the survey of those who did face prior authorization at some point in their care. What percentage were negatively impacted, and what negative effects did you see the most?

Dr. Chino: We found that most patients, meaning over two-thirds of patients, had some type of delay for their care. And for many of those patients, the delay was over two weeks. So what that means from a cancer perspective is that we have untreated symptoms.

We potentially have progressive cancer disease and we also have rising anxiety for our patients. So the burden on our patients of just having to wait for their care, of potentially getting blindsided by a denial, which is actually a quote from one of the patients on the study, we know that it's worsening their psychological burdens, as well as their cancer burden. So it's a, kind of, full picture of horrible outcomes for our patients.

Unger: Well, speaking from your perspective as a physician, how does seeing your patients who are already struggling—they're in a terrible situation having to wait two weeks facing additional challenges like that. How does it affect you?

Dr. Chino: It certainly increases burnout. I can tell you that we know that burnout is at an all time high after the pandemic. And lock step with some of the increased burdens on us as physicians from the pandemic is the increasing administrative burden from things like prior authorization.

And we know that that's a cumulative thing, which is, again, a radiation oncologist to make a prior authorization alternative plan for a patient actually doubles my work. And we know that that actually not just takes my time and adds to my burden. It actually takes my entire staff's time.

So it's not just physicians that are working kind of overtime to meet these regulatory burdens. It's also my office coordinator, my physics team, my dosimetrist team. We're talking about it's actually wasting a lot of patients time.

But ultimately, again, my time is whatever. It's the patient burden, actually, that I really want to focus on because our study found that patients were wasting their time with appeals and that it was—when we think about cancer, something where it's you really should just be able to focus on how you're getting better or making sure you're eating the best foods, making sure you're able to stay active. And the idea that we're wasting patient time by having to be on the phone with their insurance is just a bridge too far.

Unger: And that, kind of, back and forth and the burden which physicians know well but patients especially at a very vulnerable time like what you're describing, that's got to erode trust both in the physician and the health care system. Is that your observation? If it is, tell us more about that connection and what the implications are even outside of cancer treatment.

Dr. Chino: Absolutely. We specifically asked about trust in physician team and insurance and in health care systems in our survey because I really thought it as being one of those untold downstream negative implications meaning that if we start to erode trust, the wheels come off the wagon for health care.

If you don't trust that I'm looking out for you and I have the best options available to you, you're not going to get your screening mammogram. You're not going to get a COVID vaccine. You're not going to take your blood pressure medication because you don't have trust in the health care system.

And I think, again, not to tap too much on COVID, but we certainly saw the erosion of trust during the pandemic. And I think this additive administrative burden from prior authorization and being blindsided and being faced with these additional costs, I really do think it adds to this trust problem. And it's something where that sacred connection between the physician and the patient, it's really getting eroded.

Unger: For exactly the reasons that we're talking about today, fixing prior authorization is a priority for the AMA, and we know a significant part of the reform needs to come from legislators both at the state and federal level. Dr. Chino, do you have some fixes that you'd like to see and ideas on how we might break through the noise and get legislators to act on these?

Dr. Chino: I do think we have to make the process entirely more transparent, and that's what again and again and again patients will tell me is that it's so opaque it makes them feel hopeless. And providers tell it to me as well, that this lack of transparency the fact that people uninvolved in your care as a patient or in your patient's care as a provider can make a decision from on high that completely derails their cancer treatment.

It's frustrating. It's untenable. And quite frankly, it's actually more costly to the health care system. And so I think if we're able to provide the meaningful data like from our survey but also those anecdotes, those stories of the people whose cancer were progressing or whose asthma was not being treated effectively and they ended up in the hospital, those back up the data in really powerful ways as well.

So I always say to make a convincing argument, you need the data and the story because that's how you change minds. That's how you break through and say, you know what? This is a meaningful problem and it's affecting Americans every single day.

Unger: It's interesting you would say that, and I just want to highlight that because we've talked to so many folks over the past year. And everyone has the same message, which is you've got to tell those stories. And even when we talk to Congress people, they're familiar with the stories themselves too. It really resonates.

But the other piece of that, as you point out, is having the data to back that up. And that combination of things would be so important. So thank you for your contribution to both sides of that.

That's it for today's episode. We'll be back soon with another AMA Update. Be sure to subscribe for new episodes and find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us today. Please take care.


Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.

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