Prior authorizations for oral cancer drugs may delay treatment of patients
About 72.3% of oral cancer drugs required prior authorization from patient insurance companies, resulting in delays when patients could start taking these drugs.
The results of a study presented at the recent ASCO Quality Care Symposium highlighted that the process of obtaining oral cancer drugs is complex and that changes may be needed at the policy level to reduce how long a patient is getting the drugs.
In this study, researchers analyzed data from 883 patients (median age, 66 years; 44% white) who were prescribed 1,014 new oral cancer drugs from 2018 to 2019. The median time for patients to receive these medication 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 delays in getting cancer drugs, some of which are life-saving prescriptions, CURE® spoke with Joanna Fawzy Morales, Esq., CEO of Triage Cancer . She discussed the importance of standing up for yourself, even with a caring healthcare team, and not taking no for an answer from insurance companies.
CURE®: Based on the results of the study, why do you think the number of oral cancer drugs requiring prior authorization is so high?
Morales: They are expensive. Whenever insurance companies are faced with more costly claims, whether for surgery, surgery, treatment, or medication, they are more likely to put up barriers or obstacles to managing the claim. use to ensure they minimize costs. If providers do not help patients obtain pre-authorization, or if pre-authorizations are denied and patients do not appeal those denials, then patients do not have access to the care prescribed by their healthcare team. , or they have to pay out-of-pocket for this care.
Insurance companies have built a business model around the idea that people take no for an answer. In the worst case scenario, a patient will know that he can appeal a denial of prior authorization or an actual denial of 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 might face these barriers, that they do not take no for an answer, and that they exercise their rights to appeal both pre-authorization denials and care. real.
Let’s say a patient gets a denial from an insurance company. What advice would you give them regarding their rights of appeal and self-defense?
Whenever a patient faces a pre-authorization or denial, they must work with their healthcare team. There are patients who receive care in facilities where their health care team often takes care of these things without the patient’s knowledge. But there are obviously times when providers lack the capacity to go through the pre-authorization process or the appeal process on behalf of a patient. And then this burden falls on a patient. Ultimately, it is up to the patient to obtain prior authorization or to appeal the refusal. If they do not follow the rules set by their insurance company regarding pre-authorization, insurance companies can refuse to pay for this care. We want patients to understand that ultimately it is their responsibility, but that they need to work with their healthcare team because, in many cases, their healthcare team can help provide documents explaining why the care was prescribed and why it is medically necessary for the patient to obtain that care.
The problem with pre-authorizations, however, is that a patient doesn’t get a list of all the things they need to get pre-authorized for. It would actually be a useful policy change to require insurance companies to provide a list of care requiring prior authorizations to improve transparency and ease of navigation for the patient.
Additionally, in this study, researchers found that patients on Medicaid were more likely to require prior authorization than patients on Medicare. Do you have a contribution on this?
It is common with Medicaid that there are more types of care that require prior authorizations such as drugs. Prior authorizations are called processing authorization requests, or TARS. And with more states moving to a Medicaid managed care model, pre-authorizations are more commonly used with these plans, much like Medicare managed care plans.
You mentioned the ease of navigation and the policy changes that need to be made for the benefit of the patient. What else needs to happen at the political level or beyond to make this process easier and less intimidating?
Whenever we talk about usage management, it’s a balancing act between insurance companies minimizing expense and providers prescribing medically necessary treatment. There is a happy medium, but at the end of the day, insurance companies are required to pay for medically necessary care when it comes to prior approvals, step therapy, or whatever tool companies use. insurance to manage costs.
On the other side, the provider says, “This patient needs this medical care,” and when we talk about cancer care, providers usually don’t do it lightly. They have a reason why they are prescribing a particular treatment. There have been a lot of proposals to try to solve this problem or to downplay the way insurance companies use pre-authorizations. For example, one proposal is to allow providers whose recommended treatments have been approved 90% or more of the time through the pre-authorization process to skip the pre-authorization process.
There are a number of proposals to improve access to care, simplify the process and reduce administrative burdens for providers. But the data shows that pre-approvals really prevent patients from accessing the care they need or delay this process. It places a huge burden on our healthcare system when this delay in care negatively impacts a patient’s health.
When we think about what providers are going through right now in the context of a pandemic, and then adding all of these procedural hurdles that need to be overcome so that patients can access the care they would have received early in the process, it taxes the system in a way that is not necessary.
What questions should patients keep in mind when discussing a denial with their insurance company so that their treatment is not as delayed as it could be?
We recommend (to) patients that whenever they are going to receive care, they contact their insurance company to see if they need prior authorization before receiving that care. Even if they have historically received help from their providers or have just taken care of it, it is still important that the patient knows what he or she is responsible for so that if at some point there is a failure in the system, they can ensure that they obtain prior authorization. They have to follow the rules so the insurance company doesn’t come back and say, “We’re not covering any of this because you didn’t follow the rules. It might seem trivial when it comes to a $ 50 prescription, but when it comes to hundreds of thousands of dollars for treatment, surgery or a hospital stay, it adds up very quickly. We don’t want patients to find themselves in a situation where they cannot use their insurance coverage because they have not obtained prior authorization.
Why is it so important for patients to know more about the prior authorization process?
Understanding the prior approvals and the rules of your insurance plan are key ways to access the care you need, when you need it, but also to avoid unnecessary expense, which contributes to the financial burden of your plan. ‘cancer diagnosis. It’s putting one more thing on a patient’s plate to deal with. But if you can be proactive early in the process, it ends up saving you considerably in the end.
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