Nightmare on Prior Auth Street

Oct 20, 2023

With Halloween upon us, who doesn’t love a good scary story or movie?!

The longer I work in healthcare and in patient advocacy, the more I’ve come to realize that the real horror stories and things that nightmares are made of often come from the fragmentation and administrative burden that is embedded within US healthcare. These are stories that are all too frequent and stories that I wish no one needed to tell.

Prior authorization, a practice of determining the medical necessity of a treatment, procedure, or care by a health insurer, is one source of horror stories for both patients and their care teams.

A recent publication by Dr. Chino, et. al The Patient Experience of Prior Authorization in Cancer Care highlights that prior authorizations for cancer care are associated with negative outcomes for patients. Dr. Chino et al emphasize that streamlining PA is critical to improving the patient experience in and quality of cancer care.

If you are working to improve cancer care and the lives of people living with cancer, you need to know these facts inside and out.

Bottom line: the survey says that prior auth (PA) is a hot mess and an active contributor to worse outcomes in and poorer quality of cancer care.

This survey-based cross-sectional study of the patient experience highlights the adverse outcome of PA. The stats are staggering. Did you know:

22% of patients did not receive the cancer care RECOMMENDED BY THEIR DR because of PA [THIS IS NOT OK ]
most respondents experienced delays in RECOMMENDED oncology care [not experimental or off-label use care; delays in STANDARDS OF CARE that shouldn’t need PA]
delays were associated with increased anxiety, a negative perception of the PA process, increased patient administrative burden

As many of you may know, prior authorization–related delays in cancer care are very common. It’s almost as if prior auths are an expected part of the patient care journey In oncology. In 1 survey, nearly all participating oncologists (93%) said that PA delayed life-saving treatments for their patients, with 31% estimating delays exceeding 5 days. Can you imagine?

I can assure you, PA is destroying trust and the doctor-patient relationship.

This administrative burden cannot continue to fall on our doctors and on patients living with cancer. This is a solid opportunity for AI to tackle this administrative burden and level the playing field. Who’s working on it?

Nightmare on Prior Auth Street

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