Imagine you or a loved one was just diagnosed with cancer. After the shock and disbelief have subsided, you have a conversation with your oncologist and their staff about what comes next and treatment options, including scheduling infusion or radiation appointments.
Your doctor assures you there are therapies that can help fight the cancer. But too often, a doctor will delay treatment until their office receives prior approval–confirming that insurance will cover it. But, this is cancer. Shouldn’t you start therapy right away?
This scenario is common for oncology drugs and many other disease areas that require prior authorization (PA).
PAs are a utilization management tool that payers and pharmacy benefit managers (PBMs) can use to ensure that appropriate patients receive the proper treatment at the right time during their treatment journey. But many physicians do not believe that PAs are aligned to the right clinical criteria, and they can create an undue burden on patients and care teams.
According to the American Society of Clinical Oncology (ASCO), PAs place a significant burden “on patients and providers, which include delays in treatment and time taken away from patient care.”
A 2022 survey of over 1,000 practicing physicians further demonstrated that PAs can negatively affect care teams and patients. Of those surveyed, 93% said PAs can lead to delays in patient care, 91% said PAs have a somewhat or significantly negative impact on patient outcomes, and 40% said they employ a full-time staff that exclusively works on PAs.
Noticing an increase in the amount and complexity of PAs, Barbara McAneny, MD, chief executive officer of New Mexico Cancer Center in Albuquerque, New Mexico, conducted an in-practice study to evaluate the burden on her staff. The study showed that PA calls took roughly 15 minutes of office staff time for infused products and the average time to approval was 4.5 days.
Pharmaceutical manufacturers can help alleviate some of these negative effects by educating payers and PBMs on the clinical evidence required for PAs and the value of therapies on their patient populations.
PAs help ensure patient safety and control costs—they are here to stay. But by effectively demonstrating the clinical value of treatments, pharmaceutical manufacturers can help payers and PBMs create PAs based on appropriate clinical criteria, helping keep patients safe and easing the burden on care teams.
