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Madison, Wis. — One of the biggest challenges facing cancer doctors these days isn’t rising practice costs or using electronic medical records or even malpractice issues.
It’s dealing with something called “prior authorization.”
In a 2018 member survey of the American Society of Radiation Oncologists, or ASTRO, prior authorization was most commonly cited as the greatest challenge for those working in the field. Many members of the American Medical Association have also identified prior authorization as a significant obstacle to patient-centered care.
Prior authorization means that physicians must have approval from a patient’s health insurance company, in order to prescribe a certain treatment, medication or procedure. The intent is to shield patients from exorbitant medical costs and ensure the right treatment is being selected, but it can also create unintended consequences for patients and their doctors.
In addition to the medical community, the issue is now on the radar of Congress. On September 11, the U.S. House of Representatives’ Committee on Small Business heard testimony on the issue, and ASTRO chairman and UW Carbone Cancer Center’s Paul Harari, MD, was there to speak to lawmakers as an expert witness.
“Cancer patients can be particularly hard hit by this unnecessary burden and interference in care decisions,” Harari wrote in his prepared testimony to Congress.
Here’s how it works. Let’s say you receive a cancer diagnosis. Understandably, you want to start treatment as soon as possible. Your oncology team determines that radiation (or surgery or chemotherapy) is the best option and submits a request to your insurance company for prior authorization to approve the treatment.
With luck, you get a quick approval. But, for various reasons, you might also receive a denial. Perhaps the insurance company isn’t sure that the proposed treatment is the best option, or prefers what looks like a less expensive option.
“Oncologists increasingly are restricted from exercising their expert clinical judgment in determining what is in the best interest of their patients, yet they are held accountable for treatment outcomes even in situations when care decisions have been taken out of their hands by peer-reviewers. These peer reviewers are frequently not cancer specialists and therefore often unfamiliar with modern cancer treatments,” said Harari.
Another issue, Harari says, is that insurance companies may initially deny a request, only to reverse the decision upon appeal. “Many prior authorization practices are merely unnecessary delay tactics insurance payers use to deter physicians,” he said.
For doctors, that means additional time spent on the phone and filing paperwork. For patients, the delays could mean days without access to potentially life-saving treatments and the additional stress that comes from not knowing what comes next.
Some radiation oncologists say they’ve also had to turn to different therapies due to excessive delays.
These are all reasons that Harari came to Capitol Hill, calling for changes to prior authorization. “Left unchecked, the current prior authorization process can lead to inferior outcomes for cancer patients, high anxiety for cancer patients and their families, increased financial repercussions as well as increased administrative burden for physicians and staff,” he said.
Change could be coming in the future, however. Bipartisan legislation introduced earlier this year called the “Improving Seniors’ Timely Access to Care Act, H.R.1307” would make changes to the way prior authorization works under Medicare Advantage plans.
“The Improving Seniors’ Timely Access to Care Act takes crucial steps to require accountability from insurance payers and benefit management companies by streamlining and standardizing prior authorization under the Medicare Advantage program and providing much-needed oversight and transparency of health insurance,” Harari said.
“We look forward to continued opportunities to work with Congress to protect cancer patients from unnecessary delays in care and the provision of suboptimal care due to prior authorization,” he added.