3 Statistics on How Prior Authorization Affects Cancer Care

Prior authorization (PA) is a process that requires the provider to obtain approval from the insurer before prescribing or delivering certain treatments or services to the patient. PA is intended to ensure that the treatment or service is medically necessary, appropriate, and cost-effective for the patient’s condition. It is also used to prevent fraud, abuse, and overuse of healthcare resources.

However, prior authorization can also pose challenges and barriers for patients and providers, especially for those with cancer, who often need timely and complex care. Prior authorization can cause delays, denials, and disruptions in cancer care, which can affect the quality, outcomes, and costs of care. Prior authorization can also increase administrative burden and stress for patients and providers, who must deal with multiple forms, phone calls, and appeals.

Here are three statistics that illustrate the impact of prior authorization on cancer care, based on recent studies and surveys:

• 74% of physicians reported that prior authorization led to patients abandoning treatment. According to a 2019 survey by the American Medical Association (AMA), 74% of physicians said that prior authorization resulted in patients not receiving their recommended course of treatment. The survey also found that 90% of physicians believed that prior authorization had a negative impact on clinical outcomes, 24% of physicians reported that prior authorization led to a serious adverse event for a patient, and 16% of physicians reported that prior authorization led to a hospital admission.

• 19% of prior authorization requests for imaging were initially denied, most often for endocrine and gastrointestinal cancers. A recent study by researchers from the University of Pennsylvania analyzed the prior authorization data for imaging requests for 3,680 patients with cancer who were treated at a large academic medical center in 2019. The study found that 19% of the requests were initially denied by the insurers, and that the denial rate varied by cancer type, ranging from 9% for breast cancer to 36% for endocrine cancer. The study also found that the most common reasons for denial were lack of clinical information, inappropriate imaging modality, and inappropriate imaging frequency.

• 20% of adults on Medicaid reported that their insurer had denied or delayed prior approval for treatment, service, visits, or drugs. A 2019 report by the Kaiser Family Foundation (KFF) examined the experiences and perspectives of Medicaid beneficiaries who were enrolled in managed care plans, which are private health plans that contract with Medicaid to provide benefits and services to beneficiaries. The report found that 20% of the beneficiaries said that their insurer had denied or delayed prior approval for something that they or their doctor had requested in the past year, such as a treatment, service, visit, or drug. The report also found that 12% of the beneficiaries said that they had problems getting the care they needed because of PA or other insurance rules.

These statistics show that prior authorization can have a negative impact on cancer care, and that there is a need for reform and improvement of the process. Some of the possible solutions that have been proposed or implemented by various stakeholders include:

• Adopting electronic prior authorization standards and processes that can facilitate data exchange and interoperability among payers and providers, and reduce the time and hassle of prior authorization requests and responses.
• Establishing evidence-based and standardized criteria and guidelines for prior authorization requirements and decisions, and ensuring that they are transparent and accessible to patients and providers.
• Limiting the use and scope of prior authorization for certain treatments or services that are proven to be effective and appropriate for the patient’s condition, and exempting certain providers or patients who meet certain performance or clinical criteria from prior authorization.
• Providing timely and clear communication and feedback to patients and providers about the prior authorization status and outcome, and offering a fair and efficient appeals process for denials or disputes.
• Monitoring and evaluating the impact of prior authorization on access, quality, and outcomes of care, and reporting and disclosing the data and results to patients, providers, and regulators.

Prior authorization is a complex and controversial issue that affects the healthcare system, especially for patients with cancer and their providers. While it can have some benefits, such as reducing waste and ensuring appropriate care, it can also have some drawbacks, such as delaying, denying, and disrupting care, and increasing administrative burden and stress. Therefore, it is important to balance the goals and interests of the payers, providers, and patients, and to find ways to improve and optimize the prior authorization process for cancer care.