Prior Authorization Process Not Effective for Retina Specialists

Prior authorizations (PA) were found to delay patient care when requesting anti–vascular endothelial growth factor (anti-VEGF) therapies, which indicates that retina specialists may not benefit from the PA process. The study findings published in JAMA Ophthalmology¹ suggests that eliminating the PA for bevacizumab is a possible solution.

Anti-VEGF treatments have been used in patients with retina diseases for nearly 2 decades; approximately 3.6 million injections of anti-VEGF agents are distributed each year in the US. PA was implemented to lessen health care costs to discourage high-cost, low-value services, and this process requires your health insurer to approve a treatment before you receive the care.² Anti-VEGF treatments have been included in those medications that require PAs. However, PAs often lead to significant administrative burden, high health care costs, and worse outcomes. This study aimed to assess the rate of approvals for anti-VEGF treatments and how current PA policies affect this administrative burden.

Prior authorizations can lead to a delay of patient care in patients with retina diseases | Image credit: Maksim Shchur - stock.adobe.com

Data for aflibercept, ranibizumab, and bevacizumab were collected for this study to gather information on the PA process; these data included medication type, results of the PA request, number of days to obtain the PA, indication for the treatment, and cumulative time to get the PA. All data were collected from January to June 2022 from 9 retina practices from 6 states in the US, 6 of which were physician owned. Google Forms was used to log their PA requests for anti-VEGF treatment. Any PA requests submitted in anticipation of future treatment were excluded.

There were 2225 total PA requests for intravitreal injections that met the inclusion criteria. Of these, 96.2% overall were approved and 40% were approved on the same day. A total of 59.6% led to a delay in care delivery. The population that did not have an authorization within the same day was assessed to understand the length of time until approval. A total of 23.9% were authorized within 1 day, 15.9% in 2 to 3 days, 21.5% in 4 to 7 days, 26.3% within 8 to 31 days, and 12.4% after more than 31 days.

Authorizations ranged by medication, with bevacizumab having a 99% approval rate, aflibercept having a 95% approval rate, and ranibizumab having a 96% approval rate. Step therapy made up 76% of the reasons for not approving the medication, which happened in 3.8% of cases. PA were most often requested for a reauthorization of an anti-VEGF that had been previously used by the patient (64.0%), with only 0.05% denied the authorization. Patients who required initiation of anti-VEGF treatment after being part of the medical practice for several years accounted for 8.3% of the requests, and 15% of them were denied. Changes in medication accounted for 15.6% of requests, with 4.6% of them being denied.

A total of 1742 hours were spent on PAs, with a median of 100 (range, 0-200) minutes of staff time per PA request. Of the patients with time-sensitive diseases, 42.8% experienced a delay of at least a week for their PA and 14.0% experienced a monthlong delay.

There were some limitations to this study. There were only 9 practices included in this study, which represent only a subset of practices, and regional differences are possible and may make the results less generalizable. Also, estimated costs were not calculated for the administrative burden.

Retina practices are under heavy administrative burden due to the current PA process for authorization of anti-VEGF treatment. The process is not cost, and delay of care can be an issue. The researchers concluded that alternative methods warrant consideration in the future.

References

1. Dang S, Parke W, Sodhi GS, et al. Anti-VEGF pharmaceutical prior authorization in retina practices. JAMA Ophthalmol. Published online June 27, 2024. doi:10.1001/jamaophthalmol.2024.2217

2. What is prior authorization? Cigna Healthcare. Updated October 1, 2023. Accessed July 31, 2024. https://www.cigna.com/knowledge-center/what-is-prior-authorization