The patient experience of prior authorization for cancer care: Anxiety, delays, and the erosion of trust.

Abstract

6561 Background: Prior authorization (PA) requires healthcare providers to obtain pre-approval from insurance for medical care. While PA is intended to promote evidence-based standards and reduce unnecessary care, it requires clinicians and patients to navigate an often-complex approval process. Delays or denied care can be particularly problematic for patients with cancer and their experience with PA remains unexplored. Methods: Social media recruitment enrolled adult cancer patients with a self-reported personal experience with PA to an anonymous online survey of investigator-designed questions on their experience. Descriptive statistics and univariate tests characterized survey responses, and multivariable analysis, controlling for age, diagnosis, race/ethnicity, and education, assessed associations with healthcare and insurance trust and delays in care. Results: 178 patients completed the survey; they were mostly women (90%), non-Hispanic white (84%), college graduates (81%), young [18-39 (42%), 40-54 years old (34%)] with private insurance (86%). PA was most frequently required for imaging (71%), IV chemotherapy (48%), surgery (47%), radiation (34%). Most care was ultimately given as recommended (58%); however, 20% of respondents didn’t receive recommended care due to delays or denials, and 9% received recommended care but paid out-of-pocket. PA delayed 69% of care, with 51% of patients noting a delay ≥2 weeks. Delays did not vary by demographic, clinical, insurance, or treatment factors (all p > .05). 67% of patients had to personally get involved in the PA process by either calling their insurance (53%) or filing an appeal (25%); 20% of patients and/or their caregivers spent ≥11 hours dealing with PA issues. Overall PA experience was rated as “bad” (40%) or “horrible” (32%) for most respondents. Self-reported PA-related anxiety was significantly higher than self-reported baseline anxiety (mean = 74 vs mean = 37, 0-100 scale, t = 16.6, p < .001) and was significantly correlated with time spent on PA (ρ = .16, p = .04) and overall PA experience (ρ = .34, p < .001). While 18% felt PA made them trust their cancer team less, 89% said it made them trust their insurance company less, and 83% said it made them trust the healthcare system less. Patient involvement in the PA process (vs. healthcare team handling) was associated with higher-than-expected trust in their cancer team (χ2= 19.6, p < .001), and increased odds of distrusting their insurance company (β = 5.7, 95% CI: 1.8,17.6) and distrusting the healthcare system (β = 3.2, 95% CI: 1.3,7.9). Having to file appeal was associated with 2.9 increased odds (95% CI: 1.2,7.2) of experiencing a delay in care. Conclusions: PA practices may substantially delay care for patients with cancer increasing anxiety and eroding trust in healthcare. Streamlining the PA process could both allow optimal quality of care and improve the patient experience with cancer care.