Payer-mandated changes may compromise the effectiveness of radiation therapy
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Key takeaways:
- About two-thirds of cases received authorization without changes to the requested treatment upon appeal.
- Waiting for radiation therapy approval caused a mean 7.8-day treatment delay in about one-third of patients.
Most insurance denials in radiation oncology are eventually approved through appeal, according to data published in JAMA Network Open.
However, researchers acknowledged treatment effectiveness could be compromised via payer-mandated changes in technique or dosage.
“Prior authorization can generate both significant time and financial burdens on physicians and health care practices, leading to potentially enormous organizational costs for institutions nationwide,” Jacob Y. Shin, MD, a radiation oncologist at Memorial Sloan Kettering Cancer Center, and colleagues wrote.
“In our analysis of cases with insurance-denied [radiation therapy], almost two-thirds of [radiation therapy] plans were approved on appeal without changes; this requires significant effort from clinician teams,” they added. “Resources and staff time dedicated to insurance appeals could instead be used to focus on patient-specific care, and cancer centers with limited resources and/or staffing shortages may find themselves under-resourced to make timely appeals. This may also ultimately affect rural or other disadvantaged populations more discretely.”
Background and methodology
Cancer care insurance barriers present a significant burden for both patients and clinicians. Researchers from Sloan Kettering conducted a single-institution cohort analysis to investigate the potential association between insurance denials with changes in technique, dose and time to delivery of radiation oncology treatment.
Shin and colleagues collected data from patients with payer-denied authorization from Nov. 1, 2021, to Dec. 8, 2022, with data being analyzed from Dec. 15, 2022, to Dec. 31, 2023.
Researchers identified 206 cases (57.3% women; median age, 58 years), with 199 (96.6%) being commercial payers and seven (3.4%) being through Medicare or Medicare Advantage.
Results, next steps
Of the 206 total cases, researchers found 127 (61.7%) received authorization without any change to the requested radiation therapy technique or dose; 56 cases (27.2%) received authorization after modification to radiation therapy technique and/or dose required by the payer.
Among the 21 cases with a required dose change, researchers noted a median decrease in dose of 24 Gy (range, 2.3-51).
Of the 202 cases (98.1%) where radiation therapy could be delivered, 72 (34.9%) patients received delayed treatment for a mean of 7.8 days and a median of 5 days (range, 1-49).
In total, four cases (1.9%) did not receive any authorization, with three (1.5%) not undergoing radiation therapy and one (0.5%) seeking treatment at a different institution.
Researchers acknowledged potential limitations of the study, including its single-institution setting with a restricted geography, and that payer contracts and relations can vary by institution, which limits the applicability of the results.
Additional research is needed to better identify the causes for denials that also cause delays in treatment for patients, according to researchers.
“In this cohort study, most insurance denials in radiation oncology were ultimately approved on appeal; however, [radiation therapy] technique and/or effectiveness may be compromised by payer-mandated changes,” researchers wrote. “These findings suggest a clear need for further investigation and action to recognize the time and financial burdens caused by the increasing use of [prior authorization] by national insurers and the clinical impact of insurance denials on patient treatment and outcome, to establish more optimal ways to authorize and deliver radiation oncology care in a timely and cost-efficient manner, and to investigate for any possible disparities in insurer treatment authorization outcomes.”
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