Treatment, logistical, and cost burden of prior authorization in community practice.

Abstract

164 Background: Prior authorization (PA) process is complicated and labor intensive and with limited resources available to community practices, significant opportunity to reduce the costs of therapy exists by transforming this decision support process while being compliant with guidelines Methods: We retrospectively evaluated 123 patients between November 2016 and June 2016 across our three rural oncology practices with no dedicated in-house pharmacy. An established PA workflow involved two physicians, 1 nursing staff and 2 clerical staff involved in the process to manage PA for high cost imaging (PET/CT/MRI) or after a high-risk/cost prescription was initiated by a medical provider to a local pharmacy, specialty or mail-order pharmacy. Two Physicians determined strength of concordance with National Comprehensive Cancer Network (NCCN) guidelines. We examined approval rates, method of communications, time to approval and whether these variables were associated treatment delay and insurance provider Results: Eight decision steps were necessary to obtain a PA. Forty-nine Medicare (39%), 21 managed Medicaid (17%), 29 commercial insurance (23.5%) and 14 commercial insurances (11%) required PA mostly for targeted therapy (29%), oral chemotherapy (28%), PET/CT (24%). Approval rate was 94.3% on first attempt with only 1.6% being denied after an appeal process. 89% concordance with NCCN guidelines was seen. Median time to start treatment was 4 working days (Mean 4.7; Range 0-18 days). PA requests were associated with greatest delay in approval time with managed Medicaid (7 v 1.51 days; p < 0.0001) compared to Medicare, when specialty pharmacy was used (5.2 v 2.3 days p < 0.03) and when fax was used versus online (4.1 v 2.3 days p < 0.02). Conclusions: The impact of the PA process on care delivery and cost reduction are not clear. Current process is particularly burdensome on small practices especially given the high approval rates. Significant opportunity exists to reduce the inefficiency of this system using a computer algorithm-based PA using real-time online decision support system using NCCN guideline concordance