A study examining the work required to meet prior-authorization (PA) requirements for breast cancer medications points to significant staff time lost securing permission for covered use. The drugs were nearly always approved as medically necessary.
Researchers examined the processing steps and progress of prior-authorization requests covering 324 prescriptions for 279 breast cancer patients at Boston’s Dana-Farber Cancer Institute.
“We found that significant staff resources are diverted to meet PA requirements, which reduces the amount of time available for activities that directly affect patient outcomes and quality of care,” researchers wrote.
The investigators noted that the hospital was fortunate to have an in-house pharmacy, and “nursing staff assigned to process, manage, and execute PAs.” It is an advantage not shared by all in cancer care and that may result in a negative impact on patient care.
“At smaller centers, the cumbersome PA process may influence the use of appropriate, evidence based treatments and contribute to the well-established disparities in the delivery of cancer care by ethnicity, socioeconomic status, and insurance status,” they wrote.
The study findings are in line with longstanding AMA concerns about prior authorization, widely shared among members of the physician community. The AMA offers prior-authorization reform resources that allow physicians to make a difference with effective advocacy tools, including model legislation and an up-to-date list of state laws governing prior authorization.
The AMA conducted a physician survey spanning primary care and other specialties. On average, each physician faced nearly 30 PAs per week—13.9 for prescriptions and 15.1 for medical services. Physician and staff time averaged 14.6 hours—nearly two business days—each week to complete this PA workload. About one-third of physicians have staff working exclusively on prior authorization.
17 steps to get to “Yes”
A striking finding of research is that the 97.5 percent of the first prior-authorization requests were approved, which the researchers say “suggests that the PA process is an inefficient way to limit utilization.”
To capture all the activity required for prior authorization, the researchers created a process map, from prescription ordering through receipt of medication by the patient.
“Seventeen possible process steps and 10 decision points were required for patients to obtain medications requiring a PA,” the researchers reported. A prior-authorization contact with an insurer would be an example of a process step. A decision point would be determining the best way to do that—email, fax or phone.
In the overwhelming majority of cases, prior authorization requests were approved in less than a full day. The longest wait was 14 days.
“However, even when PAs were approved rapidly, additional delays of up to several weeks, often related to specialty pharmacy use and actual medication receipt, often were introduced,” the researchers wrote.
The article, “Prior Authorization for Medications in a Breast Oncology Practice: Navigation of a Complex Process,” was published in American Society of Clinical Oncology’s peer-reviewed Journal of Oncology Practice.
ASCO has a wide-ranging policy statement on the impact of utilization management policies. It reads, in part: “Payers should implement utilization management policies in a way that minimizes administrative burdens—specifically time and effort—on both providers and patients.”