Denial Rates Research Articles

Do Black Fintechs Matter? The Long and Winding Road to Develop Inclusive Algorithms for Social Justice

Racism in the financial sector is a complex global phenomenon involving intertwined social, economic and digital systems. Credit denial rates for black applicants suggest that financial systems have assimilated racial discrimination into their algorithms and credit scoring tools. Considering that digital tools incorporate their developers' life experiences and perspectives, and in view of the low representation of the black community in the digital startup universe, it is evident that even well-meaning fintechs are reproducing racial bias in their technology-intensive business models. In this paper, we investigate how three black-owned Brazilian fintechs design and use inclusive algorithms to decrease persistent social injustice involving racial financial inclusion. We combine the concept of socio-technical reconfiguration, taken from the South American tradition of social technology, with the three core concepts of Nancy Fraser’s theory of social justice – representation, recognition and redistribution – to analyze the process by which black-owned fintechs develop their particular solutions for combating racial bias. We found that, pressured by the need to be profitable, the lack of capital to develop their own credit scoring tools, and the low profile maintained by the black community ecosystem, black-owned fintechs focus on a sort of affirmative experimentation to gradually create original digital solutions aimed at achieving social justice in the financial system.

Contextualizing Inequities in COVID Vaccination Trends Among Project REFOCUS Pilot Sites: Racism-Related Determinants of Health.

Coronavirus disease (COVID) dashboards rarely provide insights about the racialized contexts in which vaccination inequities occur. The purpose of this study was to use the emerging Project REFOCUS dashboard to contextualize COVID vaccination patterns among 6 diverse communities. We queried the dashboard to generate descriptive statistics on vaccination trends and racism-related contextual factors among the 6 Project REFOCUS pilot sites (Albany, Georgia, Bronx, New York, Detroit, Michigan, Helena-West Helena, Arkansas, San Antonio, Texas, and Wake County, North Carolina). Vaccination rates, demographic indicators, and contextual factors differed across sites. As of October 17, 2022, the proportion of people who had received at least 1 COVID vaccine dose ranged from 58.4% (Wayne County, Michigan) to 95.0% (Wake County, North Carolina). The pilot sites with the greatest percentage of Black residents (Dougherty County, Georgia, Wayne County, Michigan, and Phillips County, Arkansas) had lower proportions of fully vaccinated people. Wayne County, Michigan, had the highest level of residential segregation between Black and White residents (78.5%) and non-White and White residents (68.8%), whereas Phillips County, Arkansas, had the highest overall mortgage denial rates (38.9%). Both counties represent settings where over 75.0% of residents report Black race and over 30.0% of the population live in poverty. The dashboard integrates racism-related factors with COVID vaccination visualizations and provides a fuller picture of the context in which COVID trends are occurring. Community organizers, researchers, policymakers, and practitioners can track racism-related factors and other social determinants of health as part of the contexts in which COVID-related inequities occur.

Cognitive functioning and psychosomatic syndromes in a subjective tinnitus sample.

Tinnitus is the perception of a sound in the absence of any corresponding external sound source. Current research suggests a relationship among emotional, cognitive, and psychosomatic symptoms and the occurrence or maintenance of chronic tinnitus. This study aimed to detect the prevalence and role of psychosomatic conditions, as defined by the Diagnostic Criteria for Psychosomatic Research (DCPR), and cognitive functioning in a group of patients with tinnitus. Sixty-two patients with subjective tinnitus and 62 non-tinnitus controls were recruited from the Otorhinolaryngology Unit of the University of Bari. Pure-tone audiometry was performed in all tinnitus subjects, and sound level tolerance was evaluated. Additionally, tinnitus handicap (Tinnitus Handicap Inventory [THI]), psychopathological symptoms (Symptom Checklist-90, Revised [SCL-90-R]), anxiety (State-Trait Anxiety Inventory [STAI-Y1/2]), depression (Beck Depression Inventory [BDI]), cognitive impairment (Mini-Mental State Examination [MMSE]), executive functions (Frontal Assessment Battery [FAB]), and psychosomatic syndromes (DCPR) were evaluated. Parametric and non-parametric tests were used to detect cognitive and symptomatological differences between patients and controls. The predictivity of these factors for tinnitus severity was studied using multiple regression (Backward Elimination). All tests were considered significant at p < 0.05 (family wise error corrected for each comparison). 69.4% tinnitus patients met multiple DCPR criteria, compared to 32.3% of controls. Tinnitus patients exhibited elevated rates of illness denial (ꭓ2 = 9.02; p < 0.009), demoralization (ꭓ2 = 8.05; p < 0.018), somatization (ꭓ2 = 4.92; p < 0.063) and functional symptoms (ꭓ2 = 5.21; p < 0.06) scoring significantly higher on the BDI, STAI-Y1, and STAI-Y2, and SCL-90-R compared to controls. Patients with tinnitus showed lower MMSE scores, compared to controls (t = -2.282; p < 0.001). No association between tinnitus severity and global cognitive impairment emerged. Conversely, executive function deficits were associated to tinnitus severity. Among the cognitive and psychological factors, only trait anxiety, one or more psychosomatic syndromes, and somatization clusters were strongly correlated with tinnitus severity. Our findings suggest a relationship between tinnitus severity, psychological, psychosomatic symptoms, and frontal impairment. Additionally, the influence of tinnitus on cognitive functions paves the way for integrated, multidisciplinary diagnostic and treatment options for patients. Although preliminary, our findings highlight the importance of early cognitive and psychological screening to improve patients' quality of life.

Has the opening of Amazon fulfillment centers affected demand for disability insurance?

An estimated 17.6% of blue-collar, manufacturing jobs were lost in the United States between 1970 and 2016. These jobs, often union-represented, provided relatively generous pay and benefits, creating a path to the middle class for individuals without a four-year college degree. Evidence suggests the closure of manufacturing facilities and resulting decline in economic opportunity increased demand for disability insurance (SSDI) among blue-collar workers. In recent years, the opening of Amazon Fulfillment Centers (FCs) has accelerated around the country, driving a wave of blue-collar job creation. We estimated the extent to which the opening of FCs affected SSDI application rates, including rates of approvals and denials, using a synthetic control group approach. We found that FC openings were associated with a 1.4% reduction in the SSDI application rate over the subsequent three years, translating to 5,528 fewer applications per year across commuting zones with an FC opening. Our findings are consistent with FC openings improving economic opportunities in local labor markets, though our confidence intervals were wide and included the null.

The impact of prior authorization review on orthopaedic subspecialty care: a prospective multicenter analysis

BackgroundPrior authorization review (PAR), in the United States, is a process that was initially intended to focus on hospital admissions and costly high-acuity care. Over time, payors have broadened the scope of PAR to include imaging studies, prescriptions, and routine treatment. The potential detrimental effect of PAR on healthcare has recently been brought into the limelight, but its impact on orthopedic subspecialty care remains unclear. This study investigated the denial rate, the duration of care delay, and the administrative burden of PAR on orthopedic subspecialty care. MethodsA prospective, multicenter study was performed analyzing the PAR process. Orthopedic shoulder and/or sports subspecialty practices from six states monitored payor-mandated PAR during the course of providing routine patient care. The insurance carrier (traditional Medicare, managed Medicare, Medicaid, commercial, worker’s compensation or government payor (i.e. Tricare, VA), location of service, rate of approval/ denial, time to approval/ denial, and administrative time required to complete process were all recorded and evaluated. ResultsOf 1,065 total PAR requests, we found a 1.5% (16/1065) overall denial rate for advanced imaging or surgery when recommended by an orthopedic subspecialist. Commercial and Medicaid insurance resulted in a small but statistically significantly higher rate of denial compared to traditional Medicare, managed Medicare, worker’s compensation, or governmental insurance (p < 0.001). The average administrative time spent on a single PAR was 19.5 minutes, and patients waited an average of 2.2 days to receive initial approval. Managed Medicare, commercial insurance, worker’s compensation, and Medicaid required approximately 3 to 4 times more administrative time to process a PAR than to traditional Medicare or other governmental insurance (p<0.001). After controlling for the payor, we identified a significant difference in approval/denial based on geographic location (p<0.001). An appeal resulted in a relatively low rate of subsequent denial (20%). However, approximately a third of all appeals remained in limbo for 30 days or more after the initial request. ConclusionThis is the largest prospective analysis to date of the impact of PAR on orthopedic subspecialty care in the United States. Nearly all PAR requests are eventually approved when recommended by orthopedic subspecialists, despite requiring significant resource utilization and delaying care. Current PAR practices constitute an unnecessary process that increases administrative burden and negatively impacts access to orthopedic subspecialty care. As healthcare shifts to value-based care, PAR should be called into question, as it does not seem to add value but potentially negatively impacts cost and timeliness of care.

Financial Impact of Imaging Examination Site of Service in the Medicare Population.

The financial sustainability of the US healthcare system is a growing concern in an environment of declining reimbursement and rising costs. Variable Centers for Medicare and Medicaid (CMS) reimbursement and denial rates for specific imaging examinations exist across sites of service, adding complexity to financial planning for healthcare organizations. Understanding the financial implications of site of service in existing CMS reimbursement for imaging may be of strategic importance for organizations going forward. Current Procedural Terminology (CPT) codes were obtained for common cross-sectional imaging examinations using the 2022 CMS Medicare Physician Fee Schedule. Using reimbursement rates with historical volumes and denial rates, a simulation was created to estimate the overall reimbursement of paired hospital outpatient departments (HOPD) and free-standing office (FSO) sites. A baseline simulation was performed with random allocation of imaging examinations between sites of service, and an optimized simulation was performed to estimate the maximum financial impact of targeted allocation between sites. These simulations were performed for paired CT and MR scanners separately. For CT, the baseline simulation estimated annual average reimbursement for combined HOPD and FSO was $3.25M. Reimbursement increased to $3.51M after optimized reallocation of studies between sites of service, resulting in an expected gain of $260,162 for a set of paired HOPD and FSO scanners. For MR, the same approach resulted in baseline reimbursement of $2.51M, increasing to $2.60M upon reallocation between sites for an expected gain of $87,532. Assuming a stable cost of service delivery, this approach would result in improved margins of 8% for CT and 3.5% for MR. There were 28 CT and 19 MRI daily patient imaging appointments at each respective HOPD and FSO scanners, unchanged between baseline and optimized cases. Differences in reimbursement rates between sites were the dominant driver of increased margins at low denial rates, although denial rates became dominant at values greater than 50%. Given CMS payment and denial rate variability, optimally allocating imaging studies between sites of service may improve reimbursement for the same services delivered. Although financial incentives exist for site allocation, such decisions should require physician input to assess safety and appropriate level of care. This work contributes to an understanding of financial incentives of existing reimbursement policy and may guide future policy design towards high value care.

Courtroom workgroup dynamics and implementation of Three Strikes reform

AbstractIn 2012, California's voters passed a ballot initiative that scaled back the state's “Three Strikes” sentencing law and permitted certain individuals who were serving 25‐to‐life prison terms to petition for resentencing and potentially release. Using analysis of original qualitative interview data supplemented with court administrative records, this study examines how characteristics of courtroom workgroup members; their intergroup dynamics; political, professional, and administrative considerations; and allocated resources were perceived by court officials to facilitate or impede the implementation of this reform in county courts. Availability of staff and budget was associated with a higher proportion of completed case dispositions in the first 2 years of implementation, but resources were not the only factor associated with timely case processing. Courtroom actors' seniority, experience, and professional security facilitated agreement on processes, schedules, and other details. Small, stable, close‐knit groups established routine procedures and developed expertise more quickly, but could not always avoid bottlenecks or delays. Less stable workgroups had higher rates of denial of petitions for resentencing. Positions toward Proposition 36 shaped by political, professional, or other priorities were perceived to influence some elected DAs' positions and line prosecutors' behavior, manifesting in cooperation, opposition, or mixed messages.

Examining discrimination in home improvement financing (Home Mortgage Disclosure Act 2012–2016) and neighborhood health in the United States

ABSTRACT Institutional racism by financial institutions historically denied Black homeowners access to home mortgage loans. An understudied aspect of the homeownership continuum is home repair and maintenance, with few studies assessing discrimination in access to funding for home improvement. Using US Home Mortgage Disclosure Act data between 2012 and 2016, we assess individual and census-tract level predictors of applying to, and being denied home improvement loans. We find non-Hispanic Black applicants are significantly more likely to be denied loans (OR: 2.28 p < 0.01), and that loans for areas with a high proportion of non-Hispanic Black residents (OR: 1.09, p < 0.01) are most likely to be denied, while applications in tracts with the highest proportion of non-Hispanic white residents (OR: 0.90, p < 0.01) are least likely to be denied. We find that white (r = 0.203), but not Black (r = 0.02) home improvement applications are correlated with the proportion of Black residents currently residing in the census tract. Additionally, at the census tract level, home improvement loan denial rates are associated with usually getting less than 7 hours of sleep, which is associated with adverse health outcomes. Future research on institutional racism should consider the social and health impacts of discrimination in home improvement loan financing for Black applicants and within Black communities.

Insurance Denial of Care for Randomized Controlled Trial-Eligible Patients: Incidence and Success Rate of Peer-To-Peer Authorization in Allowing Patients to Remain Trial-Eligible.

Insurance denials for clinical trials serve as a pertinent barrier for patients to remain trial-eligible, thus hindering the development of therapies and the overall advancement of health care. We present results from an ongoing oncology randomized clinical trial regarding insurance denials and peer-to-peer authorization (P2PA) success rate in allowing patients to remain trial-eligible. The ongoing Spine Patient Optimal Radiosurgery Treatment for Symptomatic Metastatic Neoplasms Phase II trial randomizes spine cancer patients to treatment with spine radiosurgery/stereotactic body radiation therapy (SBRT) versus conventional external beam radiation therapy (EBRT). Trial-eligible patients during the first 3 months of enrollment are examined to determine whether the option of SBRT was denied by their insurance. Advocacy for overcoming SBRT denial in P2PA centered on SBRT being recommended as a preferred treatment modality in the National Comprehensive Cancer Network guidelines, and the recent level I evidence demonstrating the advantages of SBRT over EBRT for symptomatic spine cancer. Of 15 trial-eligible patients, 3 (20%) experienced insurance denials for SBRT. P2PA resulted in the reversal of denials in all 3 patients, allowing each to remain trial-eligible for randomization between SBRT and cEBRT. Despite a clinical oncologic treatment modality for which recent Level 1 evidence is available, the insurance denial rate was 20%. A vigilant P2PA strategy focusing on highlighting National Comprehensive Cancer Network guidelines and the supporting Level 1 evidence resulted in a very high rate of reversing initial denial.

Credit Availability for Minority Business Owners in an Evolving Credit Environment

Disparities in access to small business financing through loan denials and discouragement are estimated using Federal Reserve Small Business Credit Survey data from 2016 to 2020. Substantial differences in credit denial rates continue to exist despite the growth of fintech lenders, which prior research has shown to have expanded the set of small businesses receiving credit. The pandemic period brought many direct additional changes to the business and lending environment, but these results show no evidence of trends in credit access over this period. The Paycheck Protection Program loans represented unprecedented support for small businesses that was not dependent on the credit worthiness of businesses, but minority-owned businesses are estimated to have received a smaller fraction of the funds that they applied for from the program in its 2020 implementation.

Impact of digital health technology on health insurance claims rejection rate in Ghana: a quasi-experimental study

IntroductionAn efficient medical claims billing system is critical to mitigating the challenges associated with claim denials and ensuring the sustainability of providing healthcare services. This study assessed the impact of Digital Health Technology (DHT) in reducing the claim rejection rate of health insurance claims submitted by health facilities to the National Health Insurance Authority in Ghana.MethodsThe study used longitudinal data on monthly claims adjustments due to errors from both paper-based and claims submitted using different DHT systems from 2010 to 2019. The claim rejection rate was estimated for each month. Prais-Winsten Segmented Interrupted Time-Series analysis was used to estimate the impact of DHT systems by comparing claims data before and after the system implementation for each facility. We employed meta-analysis techniques to generate a pooled impact estimate of DHT systems on the claim rejection rate of health insurance claims.ResultsThe total cost of deductions due to errors from the DHT system was significantly lower than the paper-based system (DHT = 8.15%, paper-based system = 10.13%). DHT contributed to an immediate impact of 1.31 percentage point reduction in the claim rejection rate of health insurance claims compared to the paper-based system.ConclusionThe DHT recorded lower denied claims costs than the paper-based claims system. Scaling up the use of DHT for claims submission will reduce the rate of claim denials and ensure the sustainability of providing healthcare services.

Association of area-level mortgage discrimination and guideline-concordant non–small cell lung cancer care in the United States.

3 Background: Disparities in receipt of care for non-small cell lung cancer (NSCLC) are well described. Discriminatory mortgage lending, which limits access to home ownership in specific neighborhoods overall and disproportionately for racialized groups, is a marker of systemic racism and lower levels of neighborhood investment. This may, in turn, decrease access to high quality care. We used the mortgage denial rate as a measure of housing discrimination and investigated its association with guideline-concordant NSCLC care. Methods: Mortgage denial rates were estimated at the zip code tabulation areas (ZCTAs) level using the Home Mortgage Disclosure Act (HMDA) database (2014-2019). Mortgage denial rates represent the proportion of denied home loans to total loans and were categorized into quartiles. Individuals ≥ 18 years diagnosed with NSCLC 2014-2019 were identified from the National Cancer Database and combined with HMDA. Multivariable logistic regression models examined associations between mortgage discrimination and receipt of guideline-concordant care, including surgery, chemotherapy, and chemoradiation. A multivariable Cox proportional hazard model examined the association between mortgage discrimination and time to chemotherapy initiation. Results: Cohort included 450,614 patients newly diagnosed with NSCLC resided in 33,120 ZCTAs. Individuals residing in ZCTAs with higher mortgage denial rates were more likely to be aged 45-64 years, male, non-Hispanic White, with private health insurance coverage and income &lt; $40,000/year. 69% of all patients received guideline-concordant care. Likelihood of guideline-concordant care was lower in neighborhoods with higher mortgage denial rates, adjusting for age and sex (Table). This disparity was present in all care subgroups. Time to chemotherapy initiation was longer for patients in neighborhoods with higher mortgage denial rates. Conclusions: Mortgage discrimination is adversely associated with receipt of guideline-concordant NSCLC care. Our examination of institutional practices leading to barriers in access to resources highlights the critical need to understand the pathways through which area-level mortgage denials impact receipt of equitable cancer care.[Table: see text]

Insurance Authorization Barriers in Patients Undergoing Cytoreductive Surgery and HIPEC.

Indications for cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) exist across multiple histologies, but little data exist on the impact of insurance authorization on access to these therapies. Given the evolving role of CRS/HIPEC, we sought to characterize insurance approval and delays in patients undergoing these therapies. A retrospective review was performed at a high-volume tertiary center of patients who received CRS/HIPEC from 2017 to 2021. Collected data included patient demographics, tumor histologic characteristics, insurance type, approval/denial history, and time to prior authorization approval. Descriptive statistics were performed. In total, 367 patients received CRS/HIPEC during the study period. They had a median age of 59 (IQR 49-67) years, 35% were male, and 76% were white. Of the patients requiring prior authorization, 14 of 104 (13%) patients were denied prior authorization and required appeal. Median time between authorization request and approval was 33 (IQR 28-36) days. These cases generated 410 insurance authorization requests, 94 (23%) of which were not initially approved and required appeal. The rate of upfront denial was 21.1% in patients with public insurance compared with 23.4% in patients with private insurance. Gastric cancer was the most common histology among denied cases (55%), followed by colorectal, appendiceal, and gynecologic malignancies. Despite the broadening indications for and data supporting CRS/HIPEC, a significant proportion of patients still face hurdles in attaining insurance approval and coverage for these therapies. Addressing barriers to insurance approval is imperative to decrease therapeutic delay and improve access to data-driven care.

Racial disparities in the small business loan market

ABSTRACT We investigate patterns of racial bias in small business loans denial rates in the US across different credit risk scores. Using data constructed from the 1998 Survey of Small Business Finances and Kauffman Firm Survey, we find disparities in loan approval ratings between Black and White entrepreneurs in intermediate risk categories, but not for the best and worst categories. We explain these findings with a simple and generalizable statistical discrimination model where banks hold prior beliefs of repayment probability based on the applicant’s group and observe noisy signals of creditworthiness. Our model predicts that differences in loan denial rates across groups are more pronounced at middle range values and disappear at very high and very low credit scores. Identifying the likely cause of differential treatment in the market is an important first step in improving representation of minority groups as entrepreneurs. Our findings contribute to this critical effort by delineating the nature of racial bias in the credit market and informing remediation policies.

Association and Trends in Medicare Denials and Utilization for Brain CT: Indirect Impacts by Targeted Policy Intervention?

Twenty-five years of annual Medicare Physician/Supplier Procedure Summary (PSPS) Master File data were used to assess trends in normalized volume and claim denial rates for brain computerized tomography. Alongside growth in utilization of brain computerized tomography (services, denial rates, fell from 1999-2005 and with relatively leveled growth and less denial rate volatility thereafter. More recent trends in denial rates may be related to policy interventions initially aimed at cost and volume reduction.

Speciality enzymes market predicted to see a surge in the near future

Twenty-five years of annual Medicare Physician/Supplier Procedure Summary (PSPS) Master File data were used to assess trends in normalized volume and claim denial rates for brain computerized tomography. Alongside growth in utilization of brain computerized tomography (services, denial rates, fell from 1999-2005 and with relatively leveled growth and less denial rate volatility thereafter. More recent trends in denial rates may be related to policy interventions initially aimed at cost and volume reduction.

Impact of USMLE Step-1 accommodation denial on US medical schools: A national survey.

IntroductionIn 2019, 4.6% of US-MD students self-identified as students with disabilities (SWD); many of these students will require accommodations on the USMLE Step-1 examination. Given the high-stakes nature of Step-1 for medical school advancement and residency match, SWD denied accommodations on Step-1 face considerable consequences. To date no study has investigated the rate of accommodation denial and its impact on medical school operations.MethodsTo investigate the rate of accommodation denial and evaluate whether Step-1 accommodation denial impacts medical school operations, a 10-question survey was sent to Student Affairs Deans and disability resource professionals at all fully-accredited US-MD granting programs. Two open-ended questions were analyzed using qualitative content analysis.ResultsSeventy-three of the 141 schools responded (52%). In the 2018–2019 academic year, 276 students from 73 schools applied for Step-1 accommodations. Of these, 144 (52%) were denied. Of those denied, 74/144 (51%) were delayed entry into the next phase of curriculum and 110/144 (76%) took the Step-1 exam unaccommodated. Of the 110 who took Step-1 without accommodations, 35/110 (32%) failed the exam, and 4/110 (3%) withdrew or were dismissed following exam failure. Schools reported varied investments of time and financial support for students denied accommodations, with most schools investing less than 20 hours (67%) and less than $1,000.00 (69%). Open-responses revealed details regarding the impact of denial on schools and students including frustration with process; financial and human resources allocation; delay in student progression; lack of resourcing and expertise; and emotional and financial burdens on students.DiscussionStep-1 accommodation denial has non-trivial financial, operational, and career impacts on medical schools and students alike. The cause of accommodation denial in this population requires further exploration.

Factors affecting the emotional reactions of patient relatives who receive news of death: a prospective observational study

BackgroundReporting the death of relatives to a family member is a very stressful task for physicians. Grief reactions differ from person to person.MethodsDemographic data of 100 patients who died after staying in ICU for more than three days were recorded. For each patient, one of the family members filled a form which contained their own age, gender, education level, marital status, number of children, degree of relationship, psychiatric treatment status, living in the same house as the patient, and whether they had ever visited the ICU before. Grief reactions were evaluated in five different categories: normal grief response, initial shock reaction, denial, feeling guilty and anger.ResultsWhen the death was reported, 55.0% of the relatives accepted this situation as normal, 19.0% felt guilty and 14.0% showed an initial shock reaction. The results showed that for a one-unit increase in the patient's age, the probability of the denial reaction among relatives was reduced by 746 times and the probability of feeling guilty was reduced by 698 times.ConclusionThe rate of denial and guilt in the grief reactions among patient relatives when given news of death in the intensive care unit increases with the decrease in patient age.

Mental health service utilization review patterns in a Medicaid managed care program.

The current study investigated mental health utilization review (UR) clinical service authorization requests, denials, and reasons for denial in a statewide Medicaid managed care organization (MMCO) program. Retrospective analysis of utilization review data reported by MMCOs in New York State. Data from the utilization review practices of 15 MMCOs were collected and analyzed for calendar years 2017 and 2018. The data reported are specific to mental health services and include the number of authorization requests, number of clinical denials, and the reasons specified for each denial. Analyses were undertaken to determine the UR denial rates and most common reasons for denials. A total of 264,901 requests for inpatient mental health service authorizations and 53,687 requests for outpatient mental health service authorizations were made in 2017 and 2018. Of these, 1.5% of inpatient authorization requests and 0.4% of outpatient authorization requests were denied for reasons related to medical necessity. The most common reason for inpatient mental health service denials was that the patient no longer met the standard for the requested level of care. Low UR denial rates warrant further examination of the relationship between UR and both quality of care and patient outcomes in mental health care. With the substantial resources spent on UR, findings could point to areas of potential reforms to the system that may minimize these costs and improve care for patients with mental illness.

POSB206 The Early Access Program in Portugal: A Quantitative and Qualitative Analysis

The Early Access Program (EAP), created in September 2017 as part of the regulatory framework of the National Health Technology System (SiNATS), is the Portuguese strategy to allow patients to have access to new hospital drugs before the Health Technology Assessment (HTA) process is concluded. With this research, we intend to analyze the EAP appraisals in Portugal in a quantitatively and qualitatively perspective. For this research, we analyzed the EAP published in the INFARMED's database until 31st of May 2021 and took under consideration the variables: Therapeutic Area, Number of patients, Date, Target Population and Appraisal Outcome. In the period of 2017 to 31st of May 2021, there were 120 EAPs submitted, aiming for 1250 patients, 20% of EAPs included pediatric. The number of EAPs have had a huge increase of 75% in 2019 (20 and 35 EAPs in 2018 and 2019, respectively) and stabilized in 2020 (36 EAPs, an increase of 3%). In 2021 we see already 27 submissions (average approval rate of 74%) and so an increase trend is back. The approval rate of overall EAPs is 63% (76 EAP) while 37% (44 EAP) were denied. While oncology represents more than 50% (64 EAPS; enrolling 539 patients) of the total number of EAPs, the odds of rejection are 3 times higher (OR= 3,29, p-value= 0,002) than other therapeutic areas. The number of EAPs have increased over the years, despite the stabilization of growth in 2020, possibly caused by the pandemic situation. More and more patients are having beforehand access to innovative drugs through a healthcare solution as a EAP. The most representative area is Oncology most likely because EAPs are for life threating situations, where the denial rate is higher when compared to other medicines.