Creating a "Culture of Yes" in Prior Authorization

February 27, 2020 Andrew Hertler, MD, FACP

The goals of prior authorization are worthwhile, but the process is broken and needs to be overhauled

An oncologist defending prior authorization is about as unlikely as a teenager suggesting an earlier curfew. As a practicing oncologist for 25 years, I grated against the restrictions placed on my practice by prior authorization practices, and their impact on patient care: The anguish of patients whose therapy is delayed while the insurer reviews it. The paperwork foisted on myself and clinic staff to request approval and, sometimes, to appeal denials. The disruptions to my clinic schedule to take a call from an insurance company medical reviewer—usually a primary care provider, never an oncologist—and educate them about the need for the requested therapies. Ultimately, my requests were rarely denied, but not without having tied up my practice in delays and paperwork in the meantime.

This burden is only increasing. In a 2017 American Society of Clinical Oncology survey of the nation's cancer practices, payer strains vaulted to the top of the list of stressors facing oncologists, with prior authorization the most-cited source of that payer stress. An American Medical Association survey in the same year found that practices complete about 29 prior authorizations per physician each week, consuming a combined 16 hours of provider and staff time. Nearly 80% of physicians said they had abandoned treatment associated with prior authorization at least some of the time, while 92% reported negative clinical outcomes.

Yet, if we're honest with ourselves, we should recognize that the goals of prior authorization—like that midnight curfew—are in our own best interests. Who can take issue with the idea of avoiding therapies with minimal chance of benefiting a patient, or giving preference to treatments that reduce costs without sacrificing clinical efficacy? Who's to argue with assuring physicians that they will be reimbursed for the drugs they dispense?

_q_tweetable:"We need prior authorization. But we also must completely redesign it to reduce its burden to practices, while meeting the challenges of modern oncology."_q_ 

The growing complexity of cancer care has only made effective prior authorization more critical. As targeted therapeutics emerge from the pipeline and oncology journals pile up with more findings to evaluate and translate into bedside practice, the challenge of determining the best regimen for a given patient has become overwhelmingly complex. It's near impossible for individual oncologists, let alone health plans, to stay on top of it all.

Meanwhile, the financial stakes to oncologists of coverage denials have grown rapidly. A cancer practice lays out a whopping $2 million to $4 million per oncologist each year in anticipation of reimbursement. A decade ago, when cancer drugs were far less expensive, it was less than $500,000. These practices need to know whether a drug will be covered before they dispense it, rather than hold their breath for 90 days as the claim is processed.

We need prior authorization. But we also must completely redesign it to reduce its burden to practices, while meeting the challenges of modern oncology. There are several components of a new system that can lead us from today's restrictive culture of "no" to a collaborative one of "yes," where value-based treatments are rapidly approved without extensive paperwork or abrasive processes.

Key characteristics of this system include:

Value-based clinical pathways created by oncologists

A modernized prior authorization system requires a comprehensive library of evidence-based pathways that address nearly 100% of the cancer cases that present in an oncology clinic. Developed by a panel of oncology experts, these pathways should incorporate the latest science, innovative new therapies and clinical compendia to identify the most effective, least harmful and highest value treatment options for members. Pathways need to be highly precise and personalized, accounting for patients' molecular markers, treatment goals and other factors. Because these pathways are informed by the latest science, payers will agree to approve regimens that follow them.

Instantaneous authorization of treatments following pathways

Using a clinical decision-support system, oncologists take a few minutes to enter details about a patient case, to get a list of pre-approved high-value pathways. Providers can then choose the most appropriate treatment plan based on their clinical expertise and their knowledge of the patient. When the provider selects one of these regimens, it is automatically authorized, reducing providers' burden and ensuring them that they will be reimbursed. Additionally, the system can often pre-approve a full episode of care, by bundling multiple service requests into "super authorizations" covers essential diagnostic and imaging tests, plus medical, radiation and surgical treatments.

Peer review provided by oncology experts

Despite the benefits of using evidence-based pathways, 100% compliance is not the goal. Inevitably there will be cases in which oncologists believe, with good reason, that a patient would benefit most from off-pathway regimens. Rather than letting the issue wind through a lengthy denial/appeal cycle, these requests should be rapidly triaged to clinical reviewers before submission to the payer. Typically, a utilization review nurse with oncology expertise will provide the first line of review. If this nurse cannot approve the request based on clinical criteria, the request is rapidly escalated to board-certified oncologist clinical reviewer for medical review and peer-to-peer discussion. This expert engages the prescriber to understand his or her clinical reasoning, and they collaboratively identify the most appropriate regimen for that patient. Treating denial as defeat, every effort should be made to get agreement on the path forward. In our experience, nearly 90% of those requests that go through this clinical review cycle are revised, resubmitted and approved after the discussion.

Financial alignment between payers and providers

Traditional fee-for-service reimbursement doesn't reward oncologists for prescribing high-value regimens. In fact, the more expensive the drugs they order, the larger the margin. In alternate payment models, however, they can earn a share of the savings that they achieve by prescribing evidence-based pathways. This realignment of financial interests can lead to new attitudes toward prior authorization. Rather than feeling policed by payers, oncology practices are more likely to monitor themselves, ensuring that they are ordering the most efficacious treatments at the lowest cost.

A more efficient, collaborative and value-focused prior authorization process is within reach. But we won't achieve it by fine-tuning flawed systems. We must redesign those systems to bring together payers and providers, arm them with the best available evidence, and encourage them to work together to achieve the best outcomes for their patients.


About the Author

Andrew Hertler, MD, FACP

As the chief medical officer of Evolent, Dr. Andrew Hertler is responsible for the advancement of the company's clinical quality and value-based strategy, utilization management policies and clinical thought leadership initiatives. A practicing board-certified oncologist for 30 years, he is a nationally recognized leader in oncology clinical practice. Dr. Hertler has volunteered on a number of American Society of Clinical Oncology (ASCO) committees, including the Clinical Practice, Quality of Care and Payment Reform Committees, as well as the Quality Oncology Practice Initiative Certification Program Oversight Council.

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