Arjun Gupta, MD
I breathed a sigh of relief. It was Friday afternoon of the second week of my oncology fellowship, and for the first time, I had submitted chemotherapy orders on my own without an error message popping up. I forwarded the orders to the attending physician for a required verification and second signature, and then walked into Clinic Room 6 to see Mrs R, a lovely woman who had recently received a diagnosis of hepatocellular carcinoma. We had met a few days prior and discussed her diagnosis and treatment options. We agreed on a treatment plan and to start chemotherapy the following week, while she took care of a few pending projects. She looked to be in good shape today, and we spoke for a solid 25 minutes about what to expect with chemotherapy, adverse effects to watch for, the emergency hotline phone number, and so on. After that, we said goodbye, and I went to see my next patient. Soon the attending physician got back to me and confirmed that the chemotherapy orders looked good, and she had signed them.
While wrapping up for the day, I received an email from the social worker alerting me that Mrs R’s chemotherapy might be placed on hold because approval from her insurance was still pending. I will not bore you with the details, but suffice it to sa more than 10 telephone calls were made and 20 emails exchanged over the next 30 minutes to sort out this issue, which was not resolved by the end of the day. A ton of paperwork, telephone calls, and emails followed the next Monday, and we had to delay starting Mrs R’s chemotherapy. Several team members, including nurses, social workers, financial counselors, administrators, and pharmacists, eventually worked things out, and Mrs R was able to receive her chemotherapy. The overall delay was a week.
This episode caused significant distress for Mrs R an me. Fortunately, it likely will not significantly affect he long-term outcome. This event has a good ending, at least in the short term, in that Mrs R ultimately started chemotherapy, has been tolerating it relatively well, and is getting close to the time to assess her tumor response. It was an important early lesson for me, though, in understanding that oncology is not immune to—and perhaps even more prone to—issues with getting clearance from insurance companies. It is important for oncology trainees to realize that obtaining prior authorizations is part of the oncologist’s job and be mentally prepared to deal with them. Prior authorization is a requirement instituted by insurance companies with the apparent goal of curbing healthcare costs in the setting of rising expenditures and complexity of care. It may extend into several facets of cancer care, including diagnostics (molecular testing, radiology) and therapeutics (oral and intravenous drugs, supportive medications). It is not as though prior authoriziations represent new experiences for oncology fellows. Most internal medicine residents spend hours in residency trying to obtain approval for a direct oral anticoagulant for a patient or arrange a new wheelchair for an octogenarian whose current one is on its last wheels. However, the stakes—financially and urgency-wise—are often much higher in oncology.
To confirm that this was not a one-off case and isomething oncologists deal with often, I observed and spoke with several of our faculty members. Just a couple of days in the oncology clinic were enough to convince me that this is a rampant issue. I saw attending physician after attending physician spend precious minutes on the phone with insurance companies to get tests or therapies cleared for their patients. One particular instance stands out—when an attending physician spent 45 minutes, mostly on hold, trying to get an octreotide scan cleared for a patient with a neuroendocrine tumor. The physicians’ poise, persistence, and passion to provide the best care for their patients really stood out.