Prior Authorizations for Oral Cancer Drugs May Delay Time Patients Receive Therapy


When patients with cancer are faced with receiving a prior authorization from their insurance provider for oral anticancer drugs, it is important that they advocate for themselves, according to an expert.

Approximately 72.3% of oral anticancer drugs required prior authorization from patients’ insurance companies, which led to delays when patients could start taking these drugs.

Findings from a study presented at the recent ASCO Quality Care Symposium, highlighted the fact that the process for obtaining oral anticancer drugs is complex, and changes may need to be made on a policy level to reduce the time that a patient obtains the drugs.

In this study, researchers analyzed data from 883 patients (median age, 66 years; 44% White) who were prescribed 1,014 new oral anticancer drugs from 2018 to 2019. The median time for patients to receive these drugs was seven days, with 25% of patients having to wait at least 14 days and 5% waiting at least 30 days.

To learn more about what patients can do to protect themselves against longer times to obtaining anticancer drugs, some of which are life-saving prescriptions, CURE® spoke with Joanna Fawzy Morales, Esq., chief executive officer of Triage Cancer. She discussed the importance of advocating for oneself, even with a supportive health care team, and not taking no for an answer from insurance companies.

CURE®:Based on findings from the study, why do you think the number of oral anticancer drug requiring prior authorization is so high?

Morales: They're expensive. Anytime insurance companies are faced with more expensive claims, whether it be for a procedure, surgery, treatment or a drug, they're more likely to implement utilization management barriers or hurdles to make sure that they're minimizing costs. If providers aren't helping patients get the preauthorization, or if preauthorizations are being denied and patients don’t appeal those denials, then patients are either not getting access to the care prescribed by their health care team, or they are having to pay out-of-pocket for that care.

Insurance companies have built a business model around the idea that people take no for an answer. In a worst-case scenario, a patient will know they can appeal a denial of a preauthorization or denial of actual treatment, and the insurance company will have to pay for the care because it was medically necessary. It is so important that patients understand that they could face these barriers, to not take no for an answer and to avail themselves of their rights to appeal both denials of preauthorization and actual care.

Let's say a patient gets a denial from an insurance company. What advice would you give them with regards to the rights to appeal and advocating for themselves?

Anytime a patient is facing a preauthorization or denial, they should work with their health care team. There are patients who are getting care at facilities where their health care team often takes care of these things without the patient ever knowing. But there are obviously times where providers don't have the capacity to work through the prior authorizations process or the appeals process on behalf of a patient. And then that burden falls on a patient. At the end of the day, it's the patient's responsibility to get the prior authorization or to appeal their denial. If they don't follow the rules that their insurance company has laid out about preauthorizations, then insurance companies can deny paying for that care. We want patients to understand that ultimately, it's their responsibility, but that they need to be working with their health care team because in many cases, their health care team can help provide documentation on why the care has been prescribed and why it’s medically necessary for the patient to get that care.

The problem with preauthorizations, though, is that a patient doesn't get a list of all the things that they have to get a prior authorization for. That would actually be a useful policy change, to require insurance companies to provide a list of care that requires preauthorizations to improve transparency and ease of navigation for the patient.

Also, in this study, researchers found that patients with Medicaid were more likely to require prior authorization compared to patients with Medicare. Do you have any input on that?

That's common with respect to Medicaid, that there are more types of care that require prior authorizations such as for medications. Prior authorizations are called treatment authorization requests, or TARS. And with more states moving to a Medicaid managed care model, prior authorizations are more commonly used with those plans, similar to Medicare managed care plans.

You mentioned ease of navigation and policy changes that need to be made to benefit the patient. What else needs to happen on a policy level or beyond to make this process easier and less daunting?

Anytime we're talking about utilization management, it's a balance between insurance companies minimizing expense and providers prescribing medically necessary treatment. There is a happy medium, but ultimately, insurance companies are required to pay for care that's medically necessary when you're talking about prior authorizations, step therapy, or any of the other tools that insurance companies use to manage costs.

On the other side is the provider is saying, “This patient needs this medical care,” and when we are talking about cancer care, providers typically don't do that lightly. They have a reason they're prescribing a particular treatment. There have been a lot of proposals to try to address this or to minimize the way that insurance companies use prior authorizations. For example, one proposal is to allow providers whose recommended treatments have been approved 90% of the time or more through the prior authorization process can skip the prior authorization process.

There are a number of proposals to improve access to care, simplify the process and ease provider administrative burdens. But the data show that preauthorizations really do keep patients from getting access to the care they need or delay that process. It puts a huge burden on our health care system when that delay of care negatively impacts a patient’s health.

When we think about what providers are going through right now in the context of a pandemic, then adding in all of these procedural hurdles for them to jump through just so the patients can get access to the care that they would have gotten at the beginning of the process, it taxes the system in a way that isn't necessary.

What questions should patients keep in mind when speaking with their insurance company about a denial so that their treatment isn’t as delayed as it can be?

We recommend (to) patients that anytime they're going to get any type of care, that they contact their insurance company to see if they need prior authorization before they get that care. Even if they've historically gotten help from their providers or their providers have just taken care of it, it's still important for the patient to know what they're responsible for so that if, at any point, there's a breakdown in the system, they can make sure to get the prior authorization. They need to follow the rules so that the insurance company doesn't come back and say, “We're not covering any of this because you didn't follow the rules.” That might sound insignificant when we're talking about a $50 prescription, but when we're talking about hundreds of thousands of dollars for treatment, surgery or a stay in the hospital, that adds up very quickly. We don't want patients to be in a position where they can’t use their insurance coverage because they didn’t get a preauthorization.

Why is it so important for patients to learn more about the prior authorization process?

Understanding prior authorizations and the rules of your insurance plan are key ways to get access to the care that you need, when you need it, but also not to face unnecessary out-of-pocket costs, which contribute to the financial burden of a cancer diagnosis. That's putting one more thing on a patient's plate to have to deal with. But if you can be proactive at the beginning of the process, it ends up saving you significantly at the end.

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