Research Shows Prior Authorization Denials Delay Critical Immunology Care

In a comprehensive study assessing the impact of prior authorization (PA) rejections on patients needing immunology treatments, researchers have uncovered significant disparities influenced by social determinants of health (SDOH).¹ The study, a poster presentation featured at the Academy of Managed Care Pharmacy 2024 annual meeting, focused on a 52-week period and examined pharmacy claims for patients with commercial insurance who submitted at least one claim for specific immunology products. It revealed a pattern of PA rejections that could delay necessary therapeutic treatments for various patient groups.

The burden of PA denials on clinical care has been well documented. The authors of another study, published in The American Journal of Managed Care^® found, “Respondents report that they may alter clinical decisions to avoid PA requirements and related burdens, even in cases in which use of the PA medication was clinically appropriate.”²

In the current investigation, a total of 263,475 patients, contributing to 861,428 claims, were analyzed, showing that all evaluated end points, including initial PA rejections and subsequent health care utilization, were statistically significant (P < .0001).¹ Initial PA rejections were more common among males (22.3%) compared with females (21.6%), and younger patients under 18 years faced higher PA rejection rates (27.3%) but were also more likely to eventually overcome these rejections compared with other age groups.

"Some of the regional disparities may be driven by [single payer] utilization," study author Angela Lawrence explained to AJMC® in an email. "As a follow-up to this study, we were also planning to review the regional disparities as well as urban versus rural segments in combination with patient ethnicity/race, age, and gender to potentially address any bias and subsequently review any potential policy interventions."

The results also demonstrated that Black/African American patients experienced a higher rate of PA rejections (25.1%) than the average, highlighting a racial disparity. Geographic location played a crucial role in the likelihood of facing and overcoming PA rejections, with significant differences observed across various regions.

"The largest delayed treatment initiation implication would be leveraging additional health care resources for any flare-ups," Lawrence wrote. "This was also scheduled to be part of the follow-up for this study. Additionally, for the immunological market, delay of treatment may not have as a severe impact on the patients’ outcomes and additional resource utilization; however, other specialty classes may be more severely impacted."

The study also shed light on the time and financial burden placed on patients by PA rejections. On average, it took 11.8 days to overcome a PA rejection, with a median of 9 days and a range extending from 0 to 73 days. This period of waiting could suggest a significant delay in treatment initiation for patients, impacting their health outcomes. Furthermore, these rejections and the subsequent process to overcome them often resulted in higher out-of-pocket costs for patients, adding a financial strain to their health care journey.

The conclusions drawn from this study underscore the need for a more equitable health care system where access to necessary treatments isn't hindered by bureaucratic obstacles like PA rejections. These findings highlight the importance of considering social determinants of health in healthcare policy and practice, particularly in the realm of immunology, to ensure that all patients have timely access to the treatments they need without undue financial or administrative burden.

References

1. Lawrence A, Edwards A, Fahy S. Assessment of prior authorization rejections and social determinants of health in immunology. Paper presented: The Academy of Managed Care Pharmacy 2024 annual meeting; April 15-18, 2024; New Orleans, LA. Poster Abstract M2.

2. Salzbrenner SG, Lydiatt M. Influence of prior authorization requirements on provider clinical decision-making. The American Journal of Managed Care. July 13, 2023. https://www.ajmc.com/view/influence-of-prior-authorization-requirements-on-provider-clinical-decision-making