Survey shows radiation oncology in ‘dark place’ as prior authorization burden worsens
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Key takeaways:
- Radiation oncologists reported prior authorization has caused adverse events and deaths.
- A significant number of denials are approved on appeal.
An American Society of Radiation Oncology survey has shined a spotlight on the impact prior authorization has on providers and patients.
Nearly one-third of the more than 750 radiation oncologists who participated in the survey indicated prior authorization delays led to ED visits, hospitalization or permanent disability for their patients.
In addition, 7% of respondents reported prior authorization contributed to the death of at least one of their patients.
The findings — including the “inordinate number of deaths” — highlight the growing burden prior authorization is causing, according to Fumiko Chino, MD, assistant professor in department of radiation oncology at The University of Texas MD Anderson Cancer Center and Healio Women in Oncology Peer Perspective Board member.
“This is our 2024 temperature check to see where we are and, unfortunately, it shows that we’re in a very dark place,” Chino told Healio.
“We know the patients we have had that prior authorization killed,” she added. “We have them in our hearts.”
‘Who’s watching the watchmen?’
Prior authorization can provide benefit, Chino said.
Some clinicians may use outdated information to dictate treatment, or they may not stay up to date on technological or medical advancements.
The current fee-for-service payment model means that providers get “paid per treatment,” and that may incentivize certain longer regimens, Chino said.
“If the structure of your facility is built on doing 30 treatments for breast cancer, it’s harder to figure out how to keep the lights on in 15 treatments,” Chino said.
Prior authorization’s value comes from “utilization management,” Chino said. It is intended to “[make] sure the treatments that we’re providing for our patients are truly evidence based, and that they will help and not harm them.”
She cited American Board of Internal Medicine’s Choosing Wisely campaign as an example of appropriate resource stewardship. For radiation oncology, it includes consideration of shorter treatment fractionalization or not using radiation at all.
However, she said prior authorization has seemingly been used to mitigate increasing costs of care without consideration of its effects on patients living longer, better lives.
“[Prior authorization] is the guardrails on our physician prescribing, but what we found is that there’s no guardrails on the guardrails,” Chino said. “Who’s watching the watchmen?”
Survey background
ASTRO received online survey responses from 754 radiation oncologists between September and October 2024.
Respondents represented both private practices (51%) and academic institutions (47%).
About half of radiation oncologists who responded to the survey served in urban communities (49%), with more than one-third practicing in suburban (39%) areas and 13% practicing in rural areas.
According to the survey, 85% of radiation oncologists said the prior authorization burden has “increased greatly” (60%) or “increased somewhat” (25%) in the past 3 years.
Additionally, 94% said it worsens staff burnout “significantly” (57%) or “somewhat” (37%).
These issues forced 80% of respondents to reallocate staff time to deal with prior authorization requests, and 64% had to hire more employees.
Radiation oncologists reported several issues involving care, as well:
- 92% said prior authorization delayed treatment;
- 68% said those delays lasted at least 5 days, up from 52% in 2020;
- 82% reported it caused them to use a less-optimal treatment;
- 62% said they have to use less-optimal treatment in more than 10% of cases, up from 32% in 2019;
- 58% said it forced them to not follow recommended guidelines;
- 33% reported patients stopped radiation due to prior authorization;
- 30% said prior authorization led to adverse events, including ED visits, hospitalization and disability; and
- 23% reported they had difficulties getting approval for anti-nausea medications.
“Virtually every person I see will have some sort of prior authorization that is required,” Chino said. “Whether that is a barrier and causes a delay is quite variable but, ever since the COVID-19 pandemic, the prior authorization burden we’ve been seeing in our patient clinics, institutions and societies have only gotten worse.”
‘Meaningful’ improvements
On the positive side, 77% of respondents said more than half of their prior authorization requests went through on the first attempt. That number increased from 69% in 2019.
Additionally, 76% reported more than half of their requests that initially got denied received approval on appeal, up from 62% in 2019.
On average, respondents said 71% of prior authorization requests received initial approval, and 73% that initially got denied received approval on appeal.
“I think there’s this idea that if you just say no, some amount of people will just give up,” Chino said. “They don’t have the resources to do the appeals, or they don’t have the knowhow to understand that you have to work the system to get this approved.
“Making it to the appeal is really important, but that takes resources,” Chino added. “It takes time, and I can’t see a patient or make an elegant radiation plan in that time where I’m arguing with insurance companies. At some point, it can’t just be me and my staff fighting.”
Chino identified multiple ways the process could improve.
Although an expedited appeal occurs within 72 hours — a significant improvement from a few years ago — another reduction could be “really meaningful,” Chino said.
“I’ve had patients who’ve literally had a tumor growing out of their chest,” she said. “Waiting 3 days for an appeal means there’s more cancer to treat, even just in the time between when I made the plan for them initially, and when I actually get to start their treatment. Sometimes it means the plan has to change because the tumor has gotten that much bigger in that time period. Every day matters.”
Insurance companies could also green light regimens that are always approved on appeal, Chino said. This is the concept of the Gold Card system, which has made some headway at the state level.
“Can we maybe not spin our wheels and delay patients, and just facilitate those plans that are going to be approved?” Chino said. “Why are you making the patient wait?”
Payment reform could benefit care, as well.
“ASTRO has a proposed payment model that we put forward that would essentially be bundled payments. It’s a case rate based system,” Chino said. “I want to treat someone with breast cancer in 15 treatments. This person wants to treat them in 30 treatments. Whichever is best for the patient you can do, but you’re going to get paid the same thing.”
Institutions can take their own steps to improving the prior authorization process, as MD Anderson has done, Chino said.
“It has to do with taking a deep dive in the most common insurance providers,” she said. “Looking at what are the things they point to as the reason why they’re denying X, Y or Z plan, and then making sure that we’re showing clearly why this needs to be approved, based on your own criteria. It is a lot of work. It’s a lot of investment, but I do think it benefits patients and the institution with facilitated care.”
In the end, she said growth can only occur if all parties work together to solve the problem.
“We can’t keep pointing fingers,” Chino said. “The doctors point to the insurance and the insurance points to the [pharmacy benefit managers], and then everyone points at the government. It would be nice if we could all just work together to improve care. I feel like it really would benefit people.”
Reference:
- ASTRO. How prior authorization harms cancer care: Results of a nationwide study, Dec. 24. Available at: https://www.astro.org/ASTRO/media/ASTRO/News%20and%20Publications/PDFs/PriorAuthSurvey_2024ExecutiveSummary.pdf. Published Dec. 4, 2024. Accessed Jan. 9, 2025.
For more information:
Fumiko Chino, MD, can be reached on X (formerly Twitter) @fumikochino or on Bluesky @fumikochino.bsky.social.