Posts Tagged PA

SURVEY: Prior Authorization Obstacles Unnecessarily Delay Patient Access to Cancer Treatments

SURVEY: Prior Authorization Obstacles Unnecessarily Delay Patient Access to Cancer Treatments

ARLINGTON, Va., April 25, 2019 — Restrictive prior authorization practices cause unnecessary delays and interference in care decisions for cancer patients, according to a new survey of nearly 700 radiation oncologists — physicians who treat cancer patients using radiation– released today by the American Society for Radiation Oncology (ASTRO).

Nearly all radiation oncologists (93%) said that their patients are delayed from life-saving treatments, and a third (31%) said the average delay lasts longer than five days – a full week of standard radiation treatments. These delays cause added stress and anxiety to patients already concerned about their health, and they are cause for alarm given research linking each week of delay in starting cancer therapy with a 1.2% to 3.2% increased risk of death.

In addition to prevalent treatment delays, the ASTRO physician survey illuminates other ways prior authorization negatively impacts patient outcomes and takes physicians away from caring for their patients:

Added Patient Stress

  • More than 7 in 10 radiation oncologists (73%) said their patients regularly express concern to them about the delay caused by prior authorization.
  • More than 3 in 10 radiation oncologists (32%) have been forced to use a different therapy for a substantial number of their patients (>10%) due to prior authorizations delays.

Unnecessary Delay Tactics

  • Nearly two-thirds of radiation oncologists (62%) said most denials they receive from prior authorization review are overturned on appeal.
  • Radiation oncology benefit management companies (ROBMs) required 85% of radiation oncologists to generate multiple treatment plans, which require physicians and medical physicists to spend several hours developing alternatives to their recommended course of treatment.
  • More than 4 in 10 respondents (44%) said their peer-reviews typically are not conducted by a licensed radiation oncologist.

Wasting Physician Time

  • Nearly one in five radiation oncologists (17%) said they lose more than 10% of time that they could be caring for their patients focused instead on dealing with prior authorization issues. An additional 39% spend 5-10% of their average workday on prior authorization.
  • More than 4 in 10 radiation oncologists (44%) needed prior authorization for at least half of their treatment recommendations. An additional third (37%) needed it for at least a quarter of their cases.
  • Many radiation oncologists (63%) had to hire additional staff in the last year to manage the prior authorization process.

Disproportionate Impact on Patients at Community-Based Clinics

  • Patients treated at community-based, private practices experience longer delays than those seen at academic centers. For example, average treatment delays lasting longer than a week were reported by 34% of private practitioners vs. 28% of academic physicians (p=0.005).
  • Radiation oncologists in private practice are almost twice as likely to spend more than 10% of their day focused on prior authorization, compared to physicians at academic centers (23% vs. 13%, p=0.003)

“This survey makes clear that restrictive prior authorization practices can cause unnecessary, stressful and potentially life-threatening delays for cancer patients,” said Paul Harari, MD, FASTRO, Chair of the ASTRO Board of Directors and professor and Chairman of human oncology at the University of Wisconsin-Madison. “While the system may have been designed as a path to streamline and strengthen health care, it is in fact frequently harmful to patients receiving radiation therapy. In its current form, prior authorization causes immense anxiety and wastes precious time for cancer patients.”

“Radiation oncology and cancer patients have been particularly hard hit by prior authorization’s unnecessary burden and interference in care decisions,” said Vivek Kavadi, MD, Vice Chair of ASTRO’s Payer Relations Subcommittee and a radiation oncologist at Texas Oncology. “Radiation oncologists increasingly are restricted from exercising our clinical judgment in what is in the best interest of the patient, yet we are held accountable for the outcomes of treatments where decisions have been taken out of our hands.”

In the 2018 annual ASTRO member survey, radiation oncologists named prior authorization as the greatest challenge facing the field. The burden was especially prominent among private practitioners in community-based settings, where the majority of cancer patients receive care.

The findings from ASTRO’s new physician survey align with recent reports from the American Medical Association (AMA), American Cancer Society Cancer Action Network (ACS CAN) and others, demonstrating the pervasiveness of prior authorization obstacles throughout the American health care system.

ASTRO recently signed onto a letter with the AMA and other medical societies calling for CMS to require Medicare Advantage plans to align their prior authorization requirements with a Consensus Statement on Improving the Prior Authorization Process authored jointly by leading provider and payer organizations.

Survey Methodology

An online survey was sent by email to all 3,882 U.S. based, practicing radiation oncologists in ASTRO’s member database, and 620 physicians completed the survey online. Invitations were sent in December 2018, with one email reminder in January 2019, and the survey closed in February 2019. ASTRO staff also administered paper surveys at the ASTRO Annual Meeting in October 2018 and collected 53 responses. Findings reflect the combined total of 673 radiation oncologist responses. For more information about respondent demographics, view the executive summary.



The American Society for Radiation Oncology (ASTRO) is the world’s largest radiation oncology society, with more than 10,000 members who are physicians, nurses, biologists, physicists, radiation therapists, dosimetrists and other health care professionals who specialize in treating patients with radiation therapies. The Society is dedicated to improving patient care through professional education and training, support for clinical practice and health policy standards, advancement of science and research, and advocacy. ASTRO publishes three medical journals,International Journal of Radiation Oncology • Biology • PhysicsPractical Radiation Oncology andAdvances in Radiation Oncology; developed and maintains an extensive patient website, RT Answers; and created the nonprofit foundation Radiation Oncology Institute. To learn more about ASTRO, visit our website, sign up to receive our news and follow us on our blogFacebookTwitterand LinkedIn.

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Medical Association Signs on to Letter Targeting PA Requirements

Medical Association Signs on to Letter Targeting PA Requirements

The Medical Association recently joined the American Medical Association and 85 other national medical groups and state medical associations in sending a letter to the Centers for Medicare & Medicaid  Services to urge CMS to provide guidance to Medicare Advantage plans on prior authorization processes through its 2020 Call Letter. In the jointly signed letter, the groups call upon CMS to require MA plans to selectively apply PA requirements and provide examples of criteria to be used for programs such as ordering/prescribing patterns that align with evidence-based guidelines and historically high PA approval rates. Citing the CMS Patients Over Paperwork initiative, the letter stresses this new guidance will promote safe, timely and affordable access to care for patients; enhance efficiency; and reduce administrative burden on physician practices.

The letter further explains how the prior authorization process has been found to be burdensome for health care providers, health plans and even patients and that physicians and insurers have agreed that these policy changes to eliminate PAs on those services for which there is low variation in care can promote greater transparency regarding services subject to PAs and protect patients to ensure PAs do not impact the continuity of care.

PA programs can create significant treatment barriers by delaying the start or continuation of necessary treatment, which may in turn adversely affect patient health outcomes. According to a 2018 AMA survey of 1,000 practicing physicians, 91 percent of physicians said PAs can delay a patient’s access to necessary care. These delays may have serious implications for patients and their health, as 75 percent of physicians reported that PA can lead to treatment abandonment, and 91 percent indicated that PA can have a negative impact on patient clinical outcomes. Most alarmingly, 28 percent of physicians indicated that PA has led to a serious adverse event (e.g., death, hospitalization, disability/permanent bodily damage) for a patient in their care.

Read the letter in its entirety

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STUDY: Prior Authorization Hurdles Have Led to Serious Adverse Events

STUDY: Prior Authorization Hurdles Have Led to Serious Adverse Events

FEB 5, 2019 CHICAGO — More than one-quarter of physicians surveyed, about 28 percent, report the prior authorization process required by health insurers for certain drugs, tests and treatments have led to serious or life-threatening events for their patients, according to new survey results released by the American Medical Association.

Critical physician concerns highlighted in the AMA survey include:

  • More than nine in 10 physicians (91 percent) say that prior authorizations programs have a negative impact on patient clinical outcomes.
  • Nearly two-thirds of physicians (65 percent) report waiting at least one business day for prior authorization decisions from insurers – and more than one-quarter (26 percent) said they wait three business days or longer.
  • More than nine in 10 physicians (91 percent) said that the prior authorization process delays patient access to necessary care, and three-quarters of physicians (75 percent) report that prior authorization can at least sometimes lead to patients abandoning a recommended course of treatment.
  • A significant majority of physicians (86 percent) said the burdens associated with prior authorization were high or extremely high, and a clear majority of physicians (88 percent) believe burdens associated with prior authorization have increased during the past five years.
  • Every week a medical practice completes an average of 31 prior authorization requirements per physician, which take the equivalent of nearly two business days (14.9 hours) of physician and staff time to complete.
  • To keep up with the administrative burden, more than a third of physicians (36 percent) employ staff members who work exclusively on tasks associated with prior authorization.

“The AMA is committed to attacking the dysfunction in health care by removing the obstacles and burdens that interfere with patient care,” said Dr. Resneck. “To make the patient-physician relationship more valued than paperwork, the AMA has taken a leading role by creating collaborative solutions to right-size and streamline prior authorization and help patients access safe, timely, and affordable care, while reducing administrative burdens that pull physicians away from patient care.”

In January 2017, the AMA with 16 other associations urged industry-wide improvements in prior authorization programs to align with a newly created set of 21 principles intended to ensure that patients receive timely and medically necessary care and medications and reduce the administrative burdens. More than 100 other health care organizations have supported those principles.

In January 2018, the AMA joined the American Hospital Association, America’s Health Insurance Plans, American Pharmacists Association, Blue Cross Blue Shield Association and Medical Group Management Association in a Consensus Statement outlining a shared commitment to industry-wide improvements to prior authorization processes and patient-centered care.

The AMA welcomes the opportunity to work collaboratively with health plans and others to create a partnership that lays the foundation for a more transparent, efficient, fair, and appropriately targeted prior authorization process. Please visit the AMA website to learn more about the organization’s ongoing collaborative efforts.

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Medical Association Joins Coalition for PA Reform

Medical Association Joins Coalition for PA Reform

Responding to unreasonable hurdles for patients seeking care, the Medical Association has joined a coalition including the American Medical Association and 16 other health care organizations urging health plans, benefit managers and others to reform prior authorization requirements imposed on medical tests, procedures, devices and drugs.

The coalition, which represents hospitals, medical groups, patients, pharmacists and physicians, says that requiring pre-approval by insurers before patients can get certain drugs or treatments can delay or interrupt medical services, divert significant resources from patient care and complicate medical decisions. Concerns that aggressive prior authorization programs place cost savings ahead of optimal care have led Delaware, Ohio and Virginia to recently join other states in passing strong patient protection legislation.

Given the potential barriers that prior authorization can pose to patient-centered care, the coalition is urging an industry-wide reassessment of these programs to align with a newly created set of 21 principles. Prior authorization programs could be improved by applying the principles’ common-sense concepts grouped in five broad categories:

  • Clinical validity,
  • Continuity of care,
  • Transparency and fairness,
  • Timely access and administrative efficiency, and
  • Alternatives and exemptions.

“Strict or bureaucratic oversight programs for drug or medical treatments have delayed access to necessary care, wasted limited health care resources and antagonized patients and physicians alike,” said AMA President Andrew W. Gurman, M.D. “The AMA joins the other coalition organizations in urging health insurers and others to apply the reform principles and streamline requirements, lengthy assessments and inconsistent rules in current prior authorization programs.”

The data entry and administrative tasks associated with prior authorization reduce time available for patients. According to a new AMA survey, every week a medical practice completes an average of 37 prior authorization requirements per physician, which takes a physician and their staff an average of 16 hours, or the equivalent of two business days, to process.

The AMA survey illustrates that physician concerns with the undue burdens of pre-authorizing medical care have reached a critical level. Highlights from the AMA survey include:

  • Seventy-five percent of surveyed physicians described prior authorization burdens as high or extremely high.
  • More than a third of surveyed physicians reported having staff who work exclusively on prior authorization.
  • Nearly 60 percent of surveyed physicians reported that their practices wait, on average, at least 1 business day for prior authorization decisions —and more than 25 percent of physicians said they wait 3 business days or longer.
  • Nearly 90 percent of surveyed physicians reported that prior authorization sometimes, often, or always delays access to care.

The AMA survey findings indicate there is a real opportunity to improve the patient experience while significantly reducing administrative burdens for both payers and physicians by reforming prior authorization and utilization management programs.

See also Medical Association Joins Call to CMS to Delay EHR Certification Requirements and Medical Association Urges CMS to Reduce EHR and MU Burden on Physicians

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Between Doctors & Patients: Prior Authorizations

Between Doctors & Patients: Prior Authorizations

Physicians face various regulatory and administrative hurdles in a day, but few are as frustrating, or as expensive, as prior authorizations, or PAs. Commercial insurance companies, Medicaid, Medicare and other third-party interests use PAs to reduce costs. This leaves physicians and their staff wondering when the practice of medicine became more about the dollars and cents than what makes sense for patients?

“The system is there for a reason, and we understand that,” Lee Carter, M.D., said. Dr. Carter practices family medicine in Autaugaville, a rural community in Autauga County with a population of less than 1,000. “But, it can be very frustrating, not only to the physicians and our staff, but to the patients who have to wait for their medications.

According to a 2012 Kaiser Family Foundation estimate of about 835,000 practicing physicians, 868.4 million hours are spent annually on PAs. A 2011 study by Health Affairs estimated physicians spend an average of $83,000 annually interacting with insurance plans to secure prescribed treatments, procedures or therapies for patients needing prior approvals.

In Dr. Carter’s practice, he and his partner treat a variety of issues in their patients ranging from colds and flu to more chronic conditions like diabetes and ADHD as well as procedures involving MRIs and X-rays. Each physician has a staff member devoted to prescription renewals and obtaining PAs. Still, keeping up with the demands of charting and following the rules for the payers for PAs can be daunting.

“When a patient comes in that you’ve been treating for months or even years, and you know there’s something new out there that will work better for that situation, you want to find what works best for your patient. Most of the time, that medication is going to be a generic, which is covered by most insurance plans because it’s cheaper for them and it’s cheaper for your patient. But, what if that med doesn’t work for your patient? What if your patient is allergic to that med or another med? You have to find a balance. That’s the key,” Dr. Carter said.

For specialists like oncologist Stephen Davidson, M.D., at the Montgomery Cancer Center, issues with PAs can begin when the patient checks in for the first appointment.

“There are days when I have patients who are scheduled to see me as new patients. They are at the front door. They have something that brought them here that has also emotionally disturbed them greatly. If their PA is not in place, they can’t so much as walk down the hall to see me,” Dr. Davidson said. “This happens…constantly.”

Dr. Davidson and his team see an average of 60 patients each day. During that time, he and his treatment team are also securing PAs for patients for imaging and medicine. Rarely are cancer medications generic, making them very expensive, so PAs must be secured for monthly refills, taking even more time away from patient care.

“It has become a tremendous burden,” Dr. Davidson said. “Somewhere along the way the burden of proof shifted from the insurance company to the physician. Traditionally there has been a respect for a physician’s judgment and decision making on behalf of the patient. That’s a very special and sacred relationship. Now, because of a number of factors, primarily economic, we have insurance companies that don’t respect the physician’s authority in the decision-making process.”

According to Dr. Davidson, the burden of proof isn’t specific to oncology. Physicians fighting to get the best treatment regimens for their patients have all experienced the same process with payers in trying to secure prior authorizations, and perhaps the most time consuming and frustrating part of the system is the peer-to-peer conversations in which physicians advocate on behalf of their patients with the payers.

“The problem is that in oncology specifically, and with medicine in general, it’s not black and white,” Dr. Davidson said. “There is a lot of leeway. There is a lot of individualism for treatment plans for patients, so problems start to happen when major insurance companies hire third-party companies to come in and do nothing but screen all your imaging and either green-light or red-light your treatment plans.”

For both of these physicians, the delay caused by the waiting game can put the patient’s health in the balance. Dr. Carter often encourages his patients to engage in the appeals process with their health insurance plan by calling the numbers listed on their insurance cards. Dr. Davidson has enlisted the assistance of his patients as well.

“When the patient calls the insurance company and gets into the conversation, it shows just how much the patient is concerned about the situation,” Dr. Carter said. “It absolutely helps for the patient to get involved and review with their insurance company what treatments have already been tried, and why they didn’t work. The patient is looking for a solution just as much as the physician.”

Fortunately, in Dr. Carter’s experience, a reply for a PA request usually takes 24 to 48 hours. Things get more complicated, however, for specialists like Dr. Davidson.

“There is more bureaucratic pressure placed on the medical practice and more delay and anxiety on the part of the patient (when dealing with PAs),” Dr. Davidson said. “We are a larger facility, and we have five full-time employees that deal with nothing but authorizations. It’s still a burden for us. I don’t know how smaller practices deal with it. Essentially your first swipe at the PA is a website, so someone is taking a patient’s medical record and actually typing it into an online form to see if it will fit exactly cookie-cutter into this form. The patient is not cookie cutter. There is no way to cookie cutter every patient, no matter what the specialty or situation.”

Some states have pursued legislative solutions to PA problems, but with little success, as insurance companies and their lobbyists come out in droves in opposition. As non-physicians increasingly attempt to dictate health care delivery, the Medical Association is committed to finding solutions to PAs and other related issues so that we keep health care decisions between doctors and patients.

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