Navigating the Challenges of Prior Authorization

Debra A. Patt, MD, MPH, MBA; Ethan M. Basch, MD, MSc


June 21, 2019

This transcript has been edited for clarity.

Debra A. Patt, MD, MPH, MBA: Hi. My name is Debra Patt. I am a medical oncologist and an executive vice president of Texas Oncology in Austin, Texas. Welcome to Medscape Oncology Insights. Joining me today is Dr Ethan Basch, director of the cancer outcomes research program and professor of medicine and public health at the University of North Carolina, Chapel Hill, Lineberger Comprehensive Cancer Center. Today we're talking about prior authorization and some of the financial toxicities that accompany cancer treatment. Thanks for joining me, Dr Basch.

Ethan M. Basch, MD, MSc: It's great to be here.

Patt: I know that you recognize the implications of the growing financial toxicity we have today as patients manage healthcare costs. We all agree that utilization management is an important tool to manage costs, especially around cancer care, but it's brought some burdens to the clinic.

The American Medical Association recently conducted a survey of physicians on the challenges with prior authorizations. This survey revealed that about 91% of physicians thought that prior authorizations led to delays in patient care, [28%] said that it led to a serious adverse event, and 75% said that it contributed to patient treatment abandonment. Prior authorization burden has also increased over time; 88% of physicians said that the burden has increased in the past 5 years, and 86% said that it was a high or extremely high burden to their practice.

I know I have seen that in my clinic. Five years ago, we gave chemotherapy the next day. Now it takes a week before we can give chemo, as we manage prior authorization. Our staffing requirements have tripled. What's your sense of how prior authorization has changed in your environment?

Basch: We are in an academic setting, which is a little different from a community setting, yet the barriers and challenges we face are the same. On the staffing side, we have seen a tremendous swelling of staff that we need, for not only prior authorization but also for patients, to help them work out the finances, particularly for the oral oncology drugs. In addition, the complexity of the process for prior authorization has increased. There is a fair amount of heterogeneity from payer to payer, so the path is different depending on the patient's insurance.

Patt: This is challenging. In Texas, where I practice, we have a universal prior authorization requirement, but most insurance is governed by the Employee Retirement Income Security Act (ERISA) under federal policy. State policy covers only non-ERISA plans, which involve less than 20% of the patients we see. So the vast majority have variable prior authorization documentation, and managing the complexity of that environment is challenging.

Basch: I completely agree. In our practice, we found that some of the issues can be managed by nonclinicians; but sometimes it's unclear when a physician needs to be involved or whether a nurse or nonclinician will be satisfactory. The other problem we have encountered is that in terms of the workflow, how the information is actually conveyed or how the appointments are set up varies even within a single payer. This has created a real challenge to the flow of how we manage the process. We have found that we need dedicated individuals who are essentially project-managing all of us, to figure out who's doing what and when and to make sure that we don't lose threads.

Patt: That is a staffing problem for all of us. Within our health record system, we use a clinical decision support tool for most of our pathways. As we think about therapeutic interventions for cancer, a lot of the structured elements that you consider to be the justification for medically necessary care are populated in that tool, so they're readily available. The challenge is that when you give that information to payers, especially in peer-to-peer review, people may not always know exactly what information they need; they may not always know when they're going to be able to speak to someone; or there may not be timeliness in a payer getting back to you about peer-to-peer review. So that's challenging.

Managing Prior Authorization and Peer-to-Peer Conversations

Patt: As with all utilization management, prior authorization is intended to provide high-value care, and it's not going away. It's important, but it needs to be manageable. We can make it more manageable by making sure that we have the necessary information for justification of medically necessary treatment. Guidelines can help with that. Frequently, in my dictations, I say, "As per guidelines," this is the therapy I'm prescribing or this is the radiology study I'm ordering. That way, if I have a staff member managing initial prior authorization, that information is readily available.

Also helpful is to try to manage that peer-to-peer conversation better. I find it challenging, especially because I'm out of the clinic a lot, as are you, and that peer-to-peer call may come 3 or 4 days later when I'm not in clinic. So giving my staff the appropriate medical justification for what I'm doing and making sure the documentation is clear can be helpful to negotiate those peer-to-peer conversations.

Basch: Those are great tips. In addition to the guidelines, I've found that having the applicable primary paper for a given situation can be very helpful, especially if the guideline is not entirely clear or it's difficult to cite. We have created macros within our electronic health record (EHR) system (we happen to use Epic) that you can drop in with what we call "dot phrases," which add the citation for a particular situation. That way, the citation is embedded within the patient record. We can remotely access our EHR on a portable device, so when that call comes in a few days later and we may be offsite, we can come back to it. It really is a challenge to have the appropriate citation or evidence at your fingertips, so I believe that's a really good tip.

Patt: To help with that problem, we are running a pilot program with an electronic interface between one of our practices and one payer, which is ideal and, in my opinion, should be everyone's solution. But until we get there, having that evidence clearly documented is one thing that helps.

Another point about the peer-to-peer conversation is that we often are not speaking with physicians who are in our subspecialty; it may be a retired gynecologist, for example. That's challenging because they don't always understand the intricacies of cancer care as their core medical background. So providing them with that literature can be helpful. It is also helpful if they decide to decline any kind of appeals process. They have to be transparent about the appeals process if you disagree with their medical determination. Thus, providing clarity in that respect can also be helpful.

Basch: Yes, I completely agree with that.

Addressing Financial Toxicity and Other Adverse Events

Patt: As we manage prior authorization, we know that financial toxicity is still an issue. Frequently, we have patients who are underinsured or have no insurance, and they have to manage copayments and out-of-pocket costs. This is especially true when we prescribe the oral oncolytics, which have grown in importance in cancer care. How do you manage getting payment assistance for patients?

Basch: Along with staffing up to support prior authorization, many of our practices have had to staff up to provide financial counseling for our patients. I believe the reasons are twofold. First, it has become essential to figure out mechanisms to help patients with the out-of-pocket portion of payment, particularly for the outpatient drugs; and second, it assists with our own collections. So there is actually a financial upside for the clinic or the hospital system.

The staff needs to have an understanding of all of the different payment assistance mechanisms, whether it's the manufacturer's assistance or various charities. They have to understand what is allowable with public payers versus private payers. They also have to be able to track the process over time. We have done some analyses of the pathway and the amount of messaging traffic for any given patient, and on average, there are about 15 different communications, usually over multiple days, between different individuals coordinating the different kinds of input that are necessary.

Initially this was being done by nonproviders, and then it was being done by our nurse navigators. We have now moved it to our specialty pharmacy, and it's been extremely effective. We have seen a substantial decrease in the delay to initiation of treatment—a more than 2-week improvement in the time to initiating therapy. We have about a 1-week timeframe (on average) from prescription to shipment of drug from the specialty pharmacy, when they use our specialty pharmacy. We've also seen a substantial reduction in the patient out-of-pocket obligation.

Patt: That's wonderful. We ask all of our patients to meet with financial counselors to understand the burden. How they navigate that patient assistance landscape is challenging. We, too, centralize prior authorization for oral oncolytics; they represent about 30% of our treatments and are growing in importance. Patients need to navigate that environment better because usually their out-of-pocket expense is much higher. We have social workers who help to manage some of those prior authorization landscapes. But for clinics that don't have social workers, there are patient support organizations like the Patient Advocacy Foundation that can help patients get access to patient assistance programs when they may not have that kind of robust support in the clinic.

Basch: That's a great point. We go to some lengths to connect patients with those various sources. For most of our patients who are receiving the outpatient drugs, at least for those with Medicare Part D, they'll generally spend through to their catastrophic level within the first 1-2 months, and that's already $5100 out of pocket. After that point, they're responsible for 5% of whatever their outpatient drug cost is with no cap, which I think many people fail to understand. I treat patients in North Carolina, and you're in Texas. For many of my patients, that's a very meaningful cost. We have seen patients refusing therapy.

Patt: I, too, have patients who have chosen not to take oral oncolytics because that threshold was too high for them to cross. For example, in my breast cancer practice, patients have chosen to take endocrine therapy alone, instead of endocrine therapy plus CDK4/6 inhibition—despite the fact that the progression-free survival is about a third as long—because the cost was too much to bear, even recognizing that, eventually, they would cross this catastrophic threshold and pay a lower out-of-pocket amount. That much was too much for them to have access to that critical therapy.

We live in the most amazing time of therapeutic innovation. It's the best time ever to be an oncologist. I often say it's like being an infectious disease specialist in the 1930s; we've got all the good drugs. But we have to figure out how to navigate paying for them. I am sure that's a struggle we'll continue to face.

Basch: Absolutely. Just at this American Society of Clinical Oncology meeting, we had in our plenary session the randomized phase 3 trial[1] showing that enzalutamide can be used in castration-sensitive metastatic prostate cancer. This is an important study because it provides access to a new option for patients, and there are a fair number of patients in this setting. Yet this means, on average, about 20 months of treatment with a drug that costs about $12,000 a month. An alternative is four to six cycles of upfront docetaxel, which may be more toxic in the short run but because of the differences in coverage for intravenous versus oral oncolytics is different for what the patient is facing. Thus, it's more important than ever for us to understand the insurance status of our patients and their financial situation so that we can help them make a choice about which of those treatments is most appropriate for them.

Patt: That's a great point, Ethan. Thank you for joining me for a fantastic discussion.

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