Radiation and Medical Oncology Trainee Perceptions of the Prior Authorization Process: A National Survey

Abstract

The prior authorization (PA) process, which requires providers to obtain pre-approval for services rendered in order to qualify for payment, was initially introduced to address rising health care costs. In 2017, the American Medical Association distributed a national survey that highlighted physician’ concerns about the burdens associated with PA programs and their potential negative effects on patients’ clinical outcome. However, the medical trainee perspective was not assessed. The objective of this study was to evaluate the perceptions of Radiation Oncology (RO) and Medical Oncology (MO) trainees regarding the PA process and its effect on their training and patient care. A 12-question, non-incentivized, electronic survey was distributed to residents in all ACGME accredited RO programs. This same survey was distributed to MO fellows at the corresponding institutions. Two reminder surveys were distributed two weeks apart. Descriptive statistics, tests of proportions, and Fisher’s exact test were used for statistical analysis with a two-sided p<0.05 considered statistically significant. The survey was distributed to 1519 trainees at 76 institutions with responses from 158/616 RO (25.6% response rate [RR]) and 124/889 MO trainees (14.0% RR). The majority (69.2%) reported participating in the PA process, though this differed by specialty (RO: 78.5% v. MO: 57.3%, p<0.01). Frequency of participation was higher amongst RO trainees with 58.0% reporting >2 appeals/month compared to 29.4% of MO trainees (p<0.01). Pluralities in both specialties reported spending >30 minutes on each individual appeal (38.0% of trainees overall). Trainees reported that issues with appeals would “often” or “sometimes” lead to changes in the recommended course of treatment (73.8%), and 71.0% of trainees were concerned with declines in the quality of patient care. Accordingly, 77.1% of trainees reported “somewhat” or “strongly” decreased enthusiasm for work and choice of profession, though this sentiment was more common amongst MO trainees compared to RO trainees (83.1% v. 73.7%, p=0.04). The most commonly recommended modifications by trainees included suggestions that the insurance reviewer be in the same specialty as the ordering provider (87.7%), providers be compensated for participation (82.7%), and that turn-around time should be more rapid (74.3%). Trainees in US Oncology programs are active participants in the PA process and report that PA requires a significant amount of time and negatively influences the quality of patient care and enthusiasm for their professions. Despite these repercussions, trainees will likely maintain active participation in the PA process given the high likelihood they will also engage in the PA process as practicing physicians. Adjustments to the PA process should be considered.