A Redesigned Prior Authorization is Needed in Oncology. Here's How.

Payer strains now top the list of stressors facing oncologists, with prior authorization as the most-cited source of that payer stress.

Who among oncologists hasn’t grated against the process of prior authorization: the steps to seek permission to give our best patient-care efforts, the additional paperwork to fight denials, the time spent educating medical reviewers why requested therapies are needed? When I was a practicing oncologist, the hassles doubly stung me for their implications that we weren’t doing what was best for our patients—patients whose anguish we felt as they waited on delayed therapies while under insurer review.

This burden is only increasing:

Yet who among us can take issue with prior authorization’s goals of avoiding therapies with minimal patient benefit, or giving preference to treatments that reduce costs without sacrificing efficacy? Who's to argue with assuring physicians of reimbursement for drugs they dispense?

The growing complexity of cancer care has made effective prior authorization more critical. It's become nearly impossible for individual oncologists, let alone health plans, to stay on top of emerging targeted and immuno-oncologic therapies and the plethora of new findings to be evaluated and translated to bedside practice.

Meanwhile, the financial stakes to oncologists have grown rapidly as drug prices have increased. A cancer practice lays out a whopping $2 million to $4 million per oncologist each year in anticipation of reimbursement. We need to know whether a drug will be covered before dispensing it, not hold our breath while the claim is processed.

Redesigning prior authorization 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. This system’s components are:

Value-Based Clinical Pathways Created by Oncologists: Developed by oncology experts, these pathways should address nearly any case that presents in an oncology clinic. They should incorporate the latest science and clinical compendia to identify the most effective, least harmful and highest value treatments. Pathways need to be 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 enter case details to get a list of pre-approved high-value pathways in minutes. When they select one of these regimens, it is automatically authorized, assuring reimbursement. The system can also often pre-approve full episodes of care by bundling multiple service requests into "super authorizations" covering essential diagnostic and imaging tests, plus medical, radiation and surgical treatments.

Peer Review by Oncology Experts: Oncologists sometimes believe, with good reason, in an off-pathway regimen for a patient. That’s fine—100% pathway compliance is not the goal. Rather than forcing outliers through a lengthy denial/appeal cycle, these requests should be rapidly triaged to clinical reviewers before payer submission. First-line review is typically a utilization review nurse with oncology expertise, followed, if needed, by rapid escalation to a board-certified oncologist 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.

Financial Alignment Between Payers and Providers: Traditional fee-for-service reimbursement doesn't reward oncologists for prescribing high-value regimens—the more expensive the drugs they order, the larger the margin. In alternate payment models, however, they can earn a share of the savings created when they follow evidence-based pathways. Realigning financial interests means that rather than feeling policed by payers, oncology practices are more likely to monitor themselves.

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 help them work together for the best patient outcomes.

Author Andrew Hertler, M.D., is chief medical officer for New Century Health.