Mark E. Thompson, MD
Torrie K. Fields, MPH, sees it happen all too often: A provider requests prior authorization (PA) for a treatment and the request is denied, or a request for more documentation sets off another round of delay. In the meantime, a patient who is running out of time is left in the middle of what is essentially a “game of chicken,” Fields said.
She is not a provider—she doesn’t even work in the healthcare system. Fields is a senior program manager for palliative care at Blue Shield of California, where she was recruited to “inject a sense of urgency into the way we take care of people with serious illness and their families.” This involves managing a team with wide latitude to effect changes in the role that Blue Shield plays in the continuum of care.
Often, to eliminate barriers to patient care, Fields finds herself advocating for coverage decisions within the organization. She has seen payers “inadvertently” using their time advantage in a dangerous delay process that makes life tougher for patients grappling with a cancer diagnosis.
Some oncology providers contend that payers have made the payment process more challenging so that they can rein in costs at patients’ expense.
Fields believes that 1 factor behind this trend is the growing complexity of care. “The driver is everyone is needing to cross their T’s and be evidence-based and thinking ‘OK, we have to align with X pathway.’” Sometimes the decision goes against the provider for good reason, she said, but what precedes is a drawn-out process that is painful for all concerned. Fields recalled the case of a patient with brain cancer who got a PA for radiation treatment and was denied that same treatment 2 weeks later; following an appeal and the submission of additional documentation, it became clear that, based on evidence, “they should never have approved it in the first place,” she said.
PA problems have become endemic to oncology, as they have for physicians in other specialties, according to a recent survey (Figure
Occasionally, payers reverse PAs, but there are other PA problems that are significantly more common, according to those interviewed for this article. PA hurdles that lengthen the time, paperwork, and aggravation required to get a patient treated have escalated in recent years, they said.
Figure. AMA Survery Reveals Physician Frustrations with PA Processa
Mark E. Thompson, MD, past president of the Community Oncology Alliance (COA) and head of its Government Affairs and Policy Committee, said PAs are now required for tests that have long been considered core to sound oncology practice, such as those to determine the genetic risk factor of a patient who has blood coagulation disorders. “I never had trouble ordering these tests. All of a sudden in January, all the big payers decided that this was going to be something they needed [a PA] for, which means more paperwork and going on the computer,” he said. “I get it if somebody doesn’t have a blood disorder. If they want to restrict this test and do [precertification], require it for specialties that don’t do this testing. But this is the meat of what we do. This is one of those things that [are] routine to the practice of hematology/oncology. Don’t make us [obtain a PA] every time. It’s silly.”
Thompson’s practice at the Mark H. Zangmeister Cancer Center in Columbus, Ohio, now has 7 fulltime staffers who spend the workday fulfilling PAs for 17 hematology/oncologist providers. It never used to require that much labor, but each year, Thompson said, the payer community removes more of what oncologists can do without PA.
“Practices all over the country are having to add precertification workers to get this element of the job done. It may be saving payers some money, but it’s hard to fathom how it’s benefiting the health system overall, as the extra expense and time has to come from somewhere,” Thompson said.
Other providers share Thompson’s views. An American Medical Association (AMA) survey conducted last year found that 51% of respondents felt that the PA burden had increased significantly in the past 5 years; 84% indicated that it was high or extremely high; and 54% said that the requirements often or always resulted in care delays.1
The 27-question web-based survey was administered in December 2017 and drew from a sample of 1000 practicing physicians—40% involved in primary care and 60% in specialty medical posts.