Prior Authorization Woes Could Lead to Lawsuit, Former AMA President Says at COA

Prior authorization in cancer care has become so burdensome, costly, and harmful for patients that health plans and pharmacy benefit managers (PBMs) could face a lawsuit, the former president of the American Medical Association (AMA) said during a session Thursday at the 2022 Community Oncology Conference, presented by the Community Oncology Alliance (COA).

Barbara McAneny, MD, CEO of the New Mexico Cancer Center, who served as AMA president in 2018, said the AMA has engaged a law firm to take on the issue of curtailing prior authorization, which oncologists say has become worse with increased vertical integration among health plans and PBMs, causing treatment delays and overriding doctors’ attempts to use innovative therapies.

McAneny was a panelist in “Battle Royale: Payer Utilization Management vs Physician-Directed Medicine,” which was moderated by Debra Patt, MD, PhD, MBA, vice president of Texas Oncology, and featured Leslie Bubsy, MD, chair of The US Oncology Network Pharmacy and Therapeutics Committee and an oncologist at Rocky Mountain Cancer Centers.

Although oncologists said practices have reported prior authorization abuses for years, McAneny said the situation has reached a crisis and is fueling clinician burnout. A recent demand that cancer patients be given an older, cheaper formulation of intravenous (IV) iron may be the example that propels litigation. For savings of $5 a unit, she said, patients have been forced to receive iron dextran (Infed), an iron replacement formulation known to cause more severe reactions than newer products.

McAneny described the position of some payers is, “Infed is good enough for you—good luck with that iron reaction.” Although she and Patt said going to court is never the first choice, sometimes it’s necessary. Finding the right plaintiff is the next step, McAneny said.

Both Patt and McAneny shared some alarming statistics on the burden that prior authorization creates for practices. Patt shared results of an AMA survey that showed 40% of physicians have staff who work exclusively on prior authorization, and 93% of physicians report that patients have seen care delays. Patient harms are real, she said, as “34% of physicians report that a prior authorization process has led to a serious adverse event for a patient in their care.”

McAneny’s practice did a study that examined the time spent getting patients through the prior authorization process. The average time spent waiting on hold for a single infusion approval was 18 minutes. “Now, keep in mind that we're paying these people about $20 an hour. So that's about $6 to sit on hold, which is really a good use of health care resources,” she said.

Sometimes calls went quickly; in other cases, staff were on hold up to an hour. The average number of days to get chemotherapy approved was 10.5 days. “That’s a lot of time for patients,” McAneny said.

Busby said he sees similar problems. In the past, delays getting a new therapy approved were normal, but today, there are delays even for well-established regimens. The rise of “fail first” policies—which require patients to take older, less effective treatments before trying new ones with demonstrated superiority—is harmful in cancer care, as evidence shows that using the best therapy first lead to the best outcomes. “That first treatment is very important,” he said.

When a patient who takes an older chemotherapy starts vomiting, it can be very difficult to control. The approach is “penny wise and pound foolish,” Busby said. For practices that have value-based agreements in place that focus on total cost of care, he said, “One hospitalization or one [emergency department] visit wipes out any savings.”

Patt, a breast cancer specialist, reported that payers sometimes treat all CDK4/6 inhibitors as if they are the same, even though the adverse event profile may vary, especially for patients with underlying health issues. “Just because there are 3 doesn’t mean they are all equal,” she said.

She’s seen cases where patients taking CDK4/6 inhibitors end up taking the drug for 3 months, and then must skip a month because of payer delays renewing their prescription. It’s impossible to expect the drug to be as effective when this happens.

McAneny said a root of the problem is the lack of connection between health plan officials managing the medical side of costs vs those who are managing pharmacy benefits. The pharmacy managers may be rewarded for “savings” because the costs of their decisions are borne elsewhere. “They don’t really bridge that gap very often,” she said.

Too often, health plans don’t understand the unique needs of cancer patients. Health plans try to tightly manage use of scans, McAneny said, because they worry about overuse in treatment for chronic back pain. But for a cancer patient, back pain can indicate their disease has progressed, and scans must be timely.

Use of “fail first” as a tool to enforce a restricted formulary is spreading, according to Busby. He said payers refer to barriers as “speed bumps,” because they know a certain number of physicians simply won’t push for a preferred treatment.

Even biosimilars are not exempt—some PBMs demand that oncologists use a specific biosimilar even if the practice is using a different one for the same reference product. In these cases, patients received appropriate treatment, but practices are “afraid that they won’t pay you for that treatment.”

What can be done? “There is a real role for advocacy,” Patt said. Reaching out to elected officials and lobbying partners is essential to heighten awareness, she said.

Transparency will be essential to reform prior authorization, McAneny said, because it’s clear that rebates and financial incentives are driving mandates instead of what’s best for patients. Payers and PBMs should not be allowed to dictate care based on what’s “economically advantageous to the insurance company,” she said.

“It’s all about the money.”