Findings highlight need to improve prior authorization process for cancer pain management
CHICAGO — A review of more than 1,700 prior authorization requests related to pain medication for people with cancer showed the vast majority ultimately got approved.
However, chart reviews documented uncontrolled pain and unmanageable side effects for many patients whose requests had been denied.
The findings — presented at ASCO Annual Meeting — highlight the need for a more effective and transparent prior authorization process to ensure patients receive timely access to essential pain management, researchers concluded.
“Prior authorization is a growing problem,” Fumiko Chino, MD, radiation oncologist at Memorial Sloan Kettering Cancer Center and Healio Women in Oncology Peer Perspective Board member, told Healio. “It really is impacting patient care, but much of the data we have is from the provider perspective.
“However, this research really should be patient-centered,” Chino added. “They’re the ones who are going untreated or whose symptoms are uncontrolled. It’s one thing to argue about prior authorization on Capitol Hill and show physicians are frustrated. It’s another to say patients with cancer are being harmed, and we wanted to demonstrate that harm.”
Background and methods
People with cancer who have uncontrolled pain often report poorer quality of life. Some patients require treatment breaks, and this can lead to poorer outcomes.
Long-acting opioid formulations are a component of guideline-concordant treatment for chronic severe pain.
However, prior authorization often is required for pain medications. This can result in delays for — and sometimes denials of — essential pain management.
Chino and colleagues analyzed all prior authorization requests from their center for outpatient long-acting opioid prescriptions since 2003. The requests sought approvals for pain medications including buprenorphine, fentanyl, hydromorphone, methadone, morphine, oxycodone, oxymorphone and tapentadol.
Researchers evaluated rates of prior authorization approvals and denials. In cases of denial, investigators performed chart reviews 2 weeks later of patient communications and provider notes, qualitatively summarizing the results.
Key findings
Chino and colleagues reviewed 1,752 prior authorization requests on behalf of 982 patients for new long-acting opioid prescriptions.
A majority (89.4%) of requests received approval after the prior authorization process, whereas 5.6% were denied and 4.6% were canceled after prior authorization initiation. Six requests (0.3%) had not been resolved.
““I think everyone can appreciate the fact that if a person has cancer and is experiencing cancer-related pain, that person should be treated appropriately for that pain,” Chino said. “To see that nearly 90% of prescriptions ultimately were approved, it means this barrier only served to delay appropriate pain management. Prior research we conducted showed that delay is a median of about 2 days. On one hand, someone might think that’s not horrible. But if you’re the person in pain, an extra 2 days can really matter.”
The most common long-acting opioids that required prior authorization included oxycodone (31.4% of prescriptions), fentanyl (28.6%), hydromorphone (11.7%) and methadone (7.8%).
Researchers identified 99 denials that affected 62 patients, including one patient for whom seven requests had been denied.
Agents most frequently denied included long-acting morphine (16.3%), buprenorphine (12.1%) and hydromorphone (7.3%). In contrast, only 2.8% of prior authorization requests for fentanyl were denied.
The chart review included data from 62 patients. Analyses showed a median two (range, 0-8) provider notes that mentioned pain or prior authorization barriers, and a median one (range, 0-5) patient messages or calls about the same two topics.
Patient messages documented cases of uncontrolled pain or unmanageable side effects. One patient cited a fear of “dying in pain” and others were “literally begging for relief,” Chino and colleagues wrote in their abstract.
Fourteen (22.6%) of the 62 patients affected by prior authorization denials either visited the ER or required hospital admission for pain crises or failure to thrive.
“That is a pretty persuasive number, as those visits cost far more than just paying for the pain medication,” Chino said. “In these situations, it’s far more costly to not adequately treat someone with cancer than to treat them appropriately.
“We only studied the 2-week period after denial, but this can affect a person much longer,” Chino added. “It can lead them into a spiral that ultimately can lead to far worse cancer outcomes, including death.”
Seven patients (11.3%) for whom prior authorization requests had been denied paid out of pocket for medications.
Next steps
“One thing our study didn’t do was compare the groups,” Chino said. “About one-quarter of patients in our study were hospitalized within 2 weeks of the denial, but we didn’t compare them to people who did not have face prior authorization barriers. We need to do those comparisons.”
Chino also emphasized the importance of advocacy.
“One thing I know from being on Capitol Hill twice in 1 month is that every legislative staffer said, ‘Oh yes, we hear from our constituents about this. We hear it from patients. They’re telling us their stories and this is really important,’” Chino said. “I always encourage people to email, call or write a letter to their congressional representative to tell them this is an issue that needs to be fixed. We can put patches on this at the institution level or provider level, but we need national policy that drives it, and the patient voice is really important.”
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Chino F, et al. Abstract 11004. Presented at: ASCO Annual Meeting; May 31-June 4, 2024.