Prior Authorization Linked to Treatment Delays
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Prior authorization requirements are associated with delays in treatment, with denials linked to greater glucocorticoid exposure for patients, according to data published in Arthritis Care & Research.
“As a rheumatologist, I often find myself having to deal with prior authorizations, especially for infusible medications,” Zachary S. Wallace, MD, MSc, of Massachusetts General Hospital, Harvard Medical School, told Healio Rheumatology. “I noticed that these prior authorizations were contributing to treatment delays and thought that it would be important to objectively measure the impact that these requirements were having on patients in our practice.”
To analyze the effects of prior authorization on patient outcomes, Wallace and colleagues used electronic medical records to identify and study patients who received infusible treatments at Massachusetts General Hospital’s rheumatology unit, between July 1, 2016, and June 20, 2018. In all, 225 patients with complete data on prior authorization status and documented infusions were included in the study.
For each patient, the researchers used electronic medical records to determine whether prior authorization was required and noted the health insurer’s response as well as any subsequent follow-up. Wallace and colleagues also recorded cumulative prednisone-equivalent glucocorticoid exposure in the 90 days following the date it was determined that prior authorization was required. The primary outcome was the difference in days from the medication request to infusion. Secondary outcomes included the proportion of denials as well as the differences in glucocorticoid exposure after a prior authorization request.
According to the researchers, 71% of the included patients required prior authorization. In addition, prior authorization requirements were associated with a longer median wait times for infusion — 31 days with prior authorization compared with 27 days in cases without (P = .045). Among the 21% of cases in which prior authorization was initially denied, the median wait time to infusion was 50 days.
Denials were associated with a greater median prednisone-equivalent glucocorticoid exposure in the 3 months following the request — 605 mg compared with 160 mg when a prior authorization was not required (P = .01).
Among the 33 cases that were initially denied, 82% were later approved. In all, 96% of all prior authorizations were eventually approved.
“Our findings indicate that patients face real consequences when prior authorization is required by insurance providers, especially when the initial request is denied,” Wallace said. “These requirements and their associated delays in treatment and excess steroid exposure especially impact patients with rare diseases. These observations suggest that prior authorization requirements are not simply hurdles to jump over for clinicians and patients — they are serious obstacles to providing care for rheumatology patients.” – by Jason Laday
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Barbara Kienzle, BSN, RN
The majority of medications used to treat rheumatic diseases are administered by injection or infusion, are used on a long-term basis and are very expensive, thereby posing quite a challenge to insurers in their quest to control the cost of medications. Prior authorizations are a tool used by insurers to help ensure patients are receiving the most cost-effective care available. However, obtaining a prior authorization is a time-consuming and often frustrating process for both health care professionals and patients, especially if appeals and peer-to-peer reviews are needed.
For the health care professional, time spent working on a prior authorization is time spent away from patient care. For the patient, waiting on prior authorization approval can result in additional treatment and/or time away from work — or school for the pediatric patients. In the end, prior authorization has potential to not only delay treatment and expose the patient to additional high-risk medications, but also increase the overall cost of medical care.
The study by Wallace and colleagues validates what rheumatology professional have known for a long time: Prior authorizations are a tremendous barrier to providing our patients with the medications they need in a timely manner. Even though the size of the cohort used for this study was relatively small, the conclusions drawn bear out real-world experiences with prior authorizations. Further studies are needed to validate the findings of this study as well as addressing injectable medications and the pediatric population, which also faces the additional challenge of limited approved medications.
Prior authorizations may be necessary to help control health care costs but the process is in great need of reform. This study is a great first step in providing policy makers and insurers with the hard data necessary to facilitate change and increase timely access to medications for our rheumatology patients.
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