Prior Authorization Research Articles

High sustained virologic response rates, regardless of race or socioeconomic class, in patients treated with chronic hepatitis C in community practice using a specialized pharmacy team.

Approved direct-acting antiviral (DAA) regimens against hepatitis C virus (HCV) can cure nearly all patients; however, socioeconomic disparities may impact access and outcome. This study assesses socioeconomic factors, differences in insurance coverage and the drug prior authorization process in HCV-infected patients managed in community practices partnered with a dedicated pharmacy team with expertise in liver disease. This Institutional Review Board-approved, ongoing study captures data on a cohort of 2480 patients from community practices. Patients had chronic hepatitis C and were treated with DAA regimens selected by their physician. The HCV Health Outcomes Centers Network provides comprehensive patient management including a dedicated pharmacy support team with expertise in the prior authorization process. In this cohort, 60.1% were male, 49% were Hispanic Whites (HW), 37% were Non-Hispanic Whites (NHW), and 14% were Black/African American (BAA). Eighty-seven percent of patients were treatment-naïve, 74% were infected with genotype 1 virus and 63% had advanced fibrosis/cirrhosis (F3/F4 = 68.2% HW, 65.6% BAA, 55.4% NHW). Forty percent of patients were on disability with the highest percentage in the BAA group and less than one-third were employed full time, regardless of race/ethnicity. Medicare covered 42% of BAA patients versus 32% of HW and NHW. The vast majority of HW (80%) and BAA (75%) had a median income below the median income of Texas residents. Additionally, 75% of HW and 71% of BAA had median income below the poverty level in Texas. Despite the above socioeconomic factors, 92% of all prior authorizations were approved upon first submission and patients received DAAs an average of 17 days from prescription. DAA therapy resulted in cure in 95.3% of patients (sustained virologic response = 94.8% HW, 94.0% BAA, 96.5% NHW). Despite having more advanced diseases and more negative socioeconomic factors, >94% of HW and BAA patients were cured. Continued patient education and communication with the healthcare team can lead to high adherence and > 94% HCV cure rates regardless of race/ethnicity or underlying socioeconomic factors in the community setting.

In case you haven't heard…

The National Association of Addiction Treatment Providers (NAATP) last week commended the Biden administration for its willingness to enforce parity (see story, page 6), last week. NAATP has been a leader in calling for this enforcement. The proposed regulations would mandate that insurers analyze their coverage to ensure equivalent access to mental health care based on outcomes. “Insurance companies would have to look at how they respond to requests from doctors to authorize treatments for substance use disorder and mental illness, as compared to physical ones,” NAATP said. “They would also be required to analyze their provider networks and how much they reimburse providers out of network for these services compared to physical health. Reimbursement rates are a critical issue and have exacerbated the workforce challenges for substance use treatment providers. The rule would also establish when health plans are prohibited from requiring doctors to obtain the insurers’ prior authorization to prescribe a medicine or procedure, or otherwise put‐up roadblocks for patients seeking mental health, as well as substance use treatment. Insurers could face fines for failing to offer comparable coverage for mental health. NAATP has advocated for the ability to fine insurers who continually ignore the law with few consequences.”

Evidence for the Technical Adequacy of the Teacher Social and Emotional Learning (SEL) Beliefs Scale

Implementation of social and emotional learning (SEL) programs and practices is becoming increasingly prevalent in Pre-K through Grade 12 educational settings. Research provides robust evidence to support positive outcomes associated with SEL implementation; however, we also know that implementation can be impacted by a variety of different individual and organizational factors. Teacher beliefs can influence how teachers implement SEL programming and represent an important area of study. The purpose of this study was to explore evidence for the technical adequacy of the Teacher SEL Beliefs Scale by examining the internal structure, internal consistency, and relations between subscale scores and teacher self-reported implementation fidelity of the Second Step SEL program. Confirmatory factor analysis of 103 teachers’ responses indicated that the three-factor solution found by prior authors, consisting of Comfort, Commitment, and Culture subscales, was also supported in the current sample. Moreover, ordinal logistic regression analyses suggested that the Comfort factor was significantly associated with how consistently teachers reported implementing the Second Step program. Implications for practice and future research are discussed.

One Year Into Dupilumab: Physician and Patient Experiences in Initiating Dupilumab for Pediatric Eosinophilic Esophagitis.

In 2022, the US Food and Drug Administration approved dupilumab for treatment of eosinophilic esophagitis (EoE). The aims of this study were to report physician and patient perspectives on initiating dupilumab. A 2-pronged approach was used: (1) data on physician prescribing practices was gathered via retrospective chart review of EoE patients prescribed dupilumab and (2) pediatric patients on dupilumab were approached to complete a questionnaire regarding reasons for initiation. During this time, 42 patients were prescribed dupilumab. From the physician's perspective, the primary reasons for dupilumab included nonresponse to topical corticosteroids (TCS) (52%), nonadherence (28%), adverse effects (10%), or to treat multiple atopic diseases (5%). The median dupilumab initiation time, from day prescribed to first injection, was 37 days [interquartile range (IQR) 37]. Almost all required prior authorization (PA) (98%), while 17% required letter of appeal and 2% required peer-to-peer. Fifteen patients (36%) completed the questionnaire portion of the study. From the patient's perspective, the primary reasons for dupilumab initiation included nonresponse to TCS (27%), nonadherence to TCS (27%), concern about adverse effects of TCS (7%), and treatment of multiple atopic diseases (33%). In conclusion, physicians are prescribing dupilumab primarily for nonresponse to TCS and almost all required PA with a long delay to starting dupilumab.

Opioid use disorder treatment and the role of New Jersey Medicaid policy changes: perspectives of office-based buprenorphine providers

ABSTRACT Background: In the US, seventy percent of drug-related deaths are attributed to opioids. In response to the ongoing opioid crisis, New Jersey’s (NJ) Medicaid program implemented the MATrx model to increase treatment access for Medicaid participants with opioid use disorder (OUD). The model’s goals include increasing the number of office-based treatment providers, enhancing Medicaid reimbursement for certain treatment services, and elimination of prior authorizations for OUD medications. Objectives: To explore office-based addiction treatment providers’ experiences delivering care in the context of statewide policy changes and their perspectives on treatment access changes and remaining barriers. Methods: This qualitative study used purposive sampling to recruit office-based New Jersey medications for opioid use disorder (MOUD) providers . Twenty-two providers (11 females, 11 males) discussed treatment experiences since the policy changes in 2019, including evaluations of the current state of OUD care in New Jersey and perceived outcomes of the MATrx model policy changes. Results: Providers reported the MOUD climate in NJ improved as Medicaid implemented policies intended to reduce barriers to care and increase treatment access. Elimination of prior authorizations was noted as important, as it reduced provider burden and allowed greater focus on care delivery. However, barriers remained, including stigma, pharmacy supply issues, and difficulty obtaining injectable or non-generic medication formulations. Conclusion: NJ policies may have improved access to care for Medicaid beneficiaries by reducing barriers to care and supporting providers in prescribing MOUD. Yet, stigma and lack of psychosocial supports still need to be addressed to further improve access and care quality.

Utilization Management Trends in Medicare Part D Oncology Drugs, 2010-2020

This study examines the exposure of Medicare Part D beneficiaries to utilization management, such as prior authorization, for oral oncology drugs.

Reducing roadblocks to employee health care through benefit design implications and unintended consequences of utilization management in cancer treatment

PurposeHR leaders and corporate benefits managers must balance organizational costs with decisions about which new tools and treatments will be covered by their employee health insurance plans. Getting it right can mean the difference between life and death for cancer patients. Most HR leaders, however, are not experts in cancer treatment and do not know how to make sure their plan benefits do not create roadblocks to treatment.Design/methodology/approachA total of 295 people who were diagnosed with cancer from 2019 to 2022 participated in the 2023 CancerCare Biomarker Survey, which was conducted in January 2023.FindingsCancerCare’s 2023 survey of cancer patients found that biomarker testing helped doctors tailor therapy for nearly all the patients (93%) whose cancers were tested over the past three years. Two in 10 cancer patients (20%) avoided unnecessary chemotherapy and/or radiation and one in 10 (10%) became eligible for a clinical trial because of biomarker testing.Research limitations/implicationsBiomarker testing is a necessary tool in the advancing world of precision cancer treatment. Despite the significant and demonstrable benefits to surveyed patients, three out of 10 respondents (29%) who received biomarker testing did not have the test covered by their insurance. Some survey respondents reported that biomarker test coverage was originally denied and they had to fight to get it covered. Others had to find ways to pay out-of-pocket or seek financial assistance to cover the cost of the testing.Practical implicationsUnfortunately, health insurance plans often limit cancer patients’ access to recommended biomarker testing, impose burdensome prior authorization (PA) protocols or require unaffordable cost-sharing, which can prevent or delay cancer patients’ access to optimal treatments. PA, a significant source of roadblocks to timely testing and treatment, was required by a quarter (25%) of the cancer patients surveyed.Originality/valueBiomarker testing is increasingly a health care equity issue and there are significant gaps in the rate of biomarker testing between black and white lung and colorectal cancer patients, which can lead to disparities in clinical trial participation and hinder access to the most effective treatments. A key way to address these barriers is to broaden insurance coverage of biomarker testing, as recommended by medical experts.

Insurer coverage of prostate cancer biomarkers.

Several recently-developed prostate cancer (CaP) biomarkers are recommended per national guidelines, yet feasibility of obtaining these tests is unknown. We used a national database to assess insurance coverage of CaP biomarkers. Insurance policies regarding 4K Score, ExoDx, My Prostate Score, Prostate Cancer Antigen 3, Prostate Health Index, and SelectMDx as of January 1, 2022 were extracted from the policy reporter database. Coverage was defined as a biomarker being deemed medically necessary, conditionally covered, or covered with prior authorization. Overall rates of biomarker coverage were compared by insurance type and region using Chi-squared test. SelectMDx was not covered by any queried policies and was omitted from analysis. A total of 186 insurance plans were identified among 131 payers. Of the 186 plans, 109 (59%) covered at least one biomarker, with prior authorization required for 38 (35%) of these plans. Prostate Cancer Antigen 3 and 4K Score had higher rates of coverage compared to ExoDx, Prostate Health Index, and My Prostate Score (52% and 43% vs. 26%, 26%, and 5%, respectively, P < 0.01). Medicare plans had higher rates of coverage compared to non-Medicare plans (80% Medicare vs. 17% commercial, 15% federal employer, and 13% Medicaid, P < 0.01), and nationwide plans had higher coverage rates compared to regional plans (43% nationwide vs. 32% midwest, 27% northeast, 25% south, 24% west, P < 0.01). Covered biomarkers under Medicare plans were less likely to require prior authorization compared to those covered by non-Medicare plans (12% Medicare vs. 63% commercial, 100% federal employer, 70% Medicaid, P < 0.01). Coverage of novel CaP biomarkers are relatively robust for Medicare plans but sparse for non-Medicare plans, with the majority of non-Medicare plans requiring prior authorization. Non-Medicare eligible men may face significant barriers to obtaining these tests.

Poster 343: How Does the Literature on Minimum Clinically Important Difference (MCID) Apply to the Patient Population from a Single Center: The Challenge of MCID in Anterior Cruciate Ligament Reconstruction

Objectives: The field of orthopaedic surgery continues to transition towards using patient-reported outcome measures (PROMs) to measure treatment success. Metrics such as the minimum clinically important difference (MCID) can help define treatment success, but there is no clear consensus on the methodology or application of scores in clinical medicine. MCID calculations can vary significantly based on cohort size, methodology (e.g. anchor-based versus distribution-based methods), follow-up time point, and patient-specific factors. Anterior cruciate ligament reconstruction (ACLR) is a highly prevalent procedure that provides high patient satisfaction according to PROMs such as the Knee Injury &amp; Osteoarthritis Outcome Score (KOOS) and the Single Assessment Numerical Evaluation (SANE). Both scales have MCID values reported in the ACLR literature. The purpose of this study was to identify patients that reached the literature-reported MCID values for KOOS and SANE. The secondary aim was to identify if there were any differences in demographic, injury, and treatment characteristics among patients that reach MCID for KOOS and/or SANE and those that do not. Methods: The PROM database of a single ambulatory surgical center was queried for ACLR procedures from 2009-2016. Revision procedures, concomitant ligament repairs/reconstructions, and patients without outcome data at baseline and two-year follow-up were excluded from the study. Demographic, injury, and surgical characteristics were extracted via chart review. Demographics included age, sex, and diagnosis of anxiety and/or depression. Injury characteristics included acuity of injury (≥6 months considered chronic) and presence of meniscal injuries. Surgical characteristics included body mass index (BMI), operative time, American Society of Anesthesiologists (ASA) Score, graft type, implant type, and concomitant meniscal procedures. Outcomes evaluated were KOOS and SANE after two years of ACLR. Patients were grouped according to whether they did or did not meet literature-reported MCIDs for KOOS and/or SANE. One-way analysis of variance and chi-square tests were conducted to identify group differences, with p=0.05 set as the threshold for significance. Results: A total of 322 patients were included. Most were female (62.1%) and had an average age of 28. Average BMI and operative time were 25.3 and 108.3 minutes, respectively. Most patients had an ASA score of 1 (84.1%). A total of 20.5% of patients had a mental health diagnosis of anxiety and/or depression. Most patients received a bone-tendon-bone autograft (49.1%). Only 6.8% of patients presented with a chronic injury. The proportion of patients that achieved MCID at two years for KOOS and SANE were 73.6% and 45.7%, respectively (p&lt;0.00001). The majority of patients achieving SANE MCID achieved KOOS MCID (89.8%), while just 55.7% of patients achieving KOOS MCID achieved SANE MCID. 41.0% of patients achieved MCID for both KOOS and SANE, while 21.7% of patients did not achieve MCID for any scale. Compared to patients that achieved MCID in at least one PROM, there was a significantly higher proportion of patients that underwent ACLR for chronic injuries among those that did not meet MCID (11.4% vs 5.6%, p=0.004). Surgical technique did not statistically differ among patients that achieved MCID and those that did not. Conclusions: The rates of achieving literature-reported MCID values for KOOS and SANE were significantly different within the same cohort of ACLR patients (73.6% for KOOS vs 45.7% for SANE). Only 41.0% of patients achieved MCID for both PROMs. A higher percentage of patients that did not meet MCID had chronic injuries compared to those that met at least one MCID. Treatment success in ACLR as determined by PROMs is thus a function of the tool employed and the injury/patient undergoing treatment rather than the surgery performed. This study particularly found that the timing from injury to presentation was associated with likelihood of achieving MCID. As orthopaedics continues to incorporate PROM data to determine treatment success as well as prior authorization and reimbursement policies, it is important to refine these PROMs and tailor them to patient-specific factors in order to adequately capture a successful treatment. [Table: see text][Table: see text]

Exploring the Association of State Policies and the Trajectories of Buprenorphine Prescriber Patient Caseloads.

Increasing buprenorphine access is critical to facilitating effective opioid use disorder treatment. Buprenorphine prescriber numbers have increased substantially, but most clinicians who start prescribing buprenorphine stop within a year, and most active prescribers treat very few individuals. Little research has examined state policies' association with the evolution of buprenorphine prescribing clinicians' patient caseloads. Our retrospective cohort study design derived from 2006 to 2018 national pharmacy claims identifying buprenorphine prescribers and the number of patients treated monthly. We defined persistent prescribers based on results from a k-clustering approach and were characterized by clinicians who did not quickly stop prescribing and had average monthly caseloads greater than 5 patients for much of the first 6 years after their first dispensed prescription. We examined the association between persistent prescribers (dependent variable) and Medicaid coverage of buprenorphine, prior authorization requirements, and mandated counseling policies (key predictors) that were active within the first 2 years after a prescriber's first observed dispensed buprenorphine prescription. We used multivariable logistic regression analyses and entropy balancing weights to ensure better comparability of prescribers in states that did and did not implement policies. Medicaid coverage of buprenorphine was associated with a smaller percentage of new prescribers becoming persistent prescribers (OR = 0.72; 95% CI = 0.53, 0.97). There was no evidence that either mandatory counseling or prior authorization was associated with the odds of a clinician being a persistent prescriber with estimated ORs equal to 0.85 (95% CI = 0.63, 1.16) and 1.13 (95% CI = 0.83, 1.55), respectively. Compared to states without coverage, states with Medicaid coverage for buprenorphine had a smaller percentage of new prescribers become persistent prescribers; there was no evidence that the other state policies were associated with changes in the rate of clinicians becoming persistent prescribers. Because buprenorphine treatment is highly concentrated among a small group of clinicians, it is imperative to increase the pool of clinicians providing care to larger numbers of patients for longer periods. Greater efforts are needed to identify and support factors associated with successful persistent prescribing.

Exploiting subspace constraints and ab initio variational methods for quantum chemistry

Variational methods offer a highly promising route to exploiting quantum computers for chemistry tasks. Here we employ methods described in a sister paper to the present report, entitled exploring ab initio machine synthesis of quantum circuits, in order to solve problems using adaptively evolving quantum circuits. Consistent with prior authors we find that this approach can outperform human-designed circuits such as the coupled-cluster or hardware-efficient ansätze, and we make comparisons for larger instances up to 14 qubits Moreover we introduce a novel approach to constraining the circuit evolution in the physically relevant subspace, finding that this greatly improves performance and compactness of the circuits. We consider both static and dynamics properties of molecular systems. The emulation environment used is QuESTlink all resources are open source and linked from this paper.

Poster 317: Preoperative and Operative Characteristics in the Context of Patient-Reported Outcomes for ACLR in Patients Aged 40 or Older: Allograft versus Autograft

Poster 317: Preoperative and Operative Characteristics in the Context of Patient-Reported Outcomes for ACLR in Patients Aged 40 or Older: Allograft versus Autograft

Influence of prior authorization requirements on provider clinical decision-making.

Prior authorization (PA) aims to promote the safe and effective use of medications and to control costs. However, PA-related administrative tasks can contribute to burden on health care providers. This study examines how such tasks affect treatment decisions. Cross-sectional, online survey. We conducted an online survey of US medical providers in 2020 based on a convenience sample of 100,000 providers. Multivariate path analysis was used to examine associations among provider practice characteristics, step therapy and other health plan requirements, perceived burdens of PA, communication issues with insurers, and prescribing behaviors (prescribing a different medication than planned, avoiding prescribing of newer medications even if evidence-based guideline recommendations are met, and modifying a diagnosis). Weighted analyses were conducted to assess nonresponse bias. A total of 1173 respondents (1.2% response rate) provided 1147 usable surveys. Step therapy requirements had the largest effect on clinical decision-making. Other significant effects on clinical decision-making included perceived PA likelihood, communication issues, and health plan requirements (eg, clinical documentation). Weighted analyses showed that the study conclusions were unlikely to have been biased by nonresponse. Respondents report that they may alter clinical decisions to avoid PA requirements and related burdens, even in cases in which use of the PA medication was clinically appropriate. Processes that reduce the administrative burden of PA through improved communication and transparency as well as standardized documentation may help ensure that PA more seamlessly achieves its goals of safe and effective use of medications.

Prior Authorizations Delay Therapy, Impact Decision-making, and Lead to Adverse Events in Inflammatory Bowel Disease: 2022 Provider Survey

Prior Authorizations Delay Therapy, Impact Decision-making, and Lead to Adverse Events in Inflammatory Bowel Disease: 2022 Provider Survey

Estimating the Effect of a Treatment When There Is Nonadherence in a Trial.

Randomized trials offer a powerful strategy for estimating the effect of a treatment on an outcome. However, interpretation of trial results can be complicated when study subjects do not take the treatment to which they were assigned; this is referred to as nonadherence. Prior authors have described instrumental variable approaches to analyze trial data with nonadherence; under their approaches, the initial assignment to treatment is used as an instrument. However, their approaches require the assumption that initial assignment to treatment has no direct effect on the outcome except via the actual treatment received (i.e., the exclusion restriction), which may be implausible. We propose an approach to identification of a causal effect of treatment in a trial with 1-sided nonadherence without assuming exclusion restriction. The proposed approach leverages the study subjects initially assigned to control status as an unexposed reference population; we then employ a bespoke instrumental variable analysis, where the key assumption is "partial exchangeability" of the association between a covariate and an outcome in the treatment and control arms. We provide a formal description of the conditions for identification of causal effects, illustrate the method using simulations, and provide an empirical application.

Letter: The Urgency of Neurosurgical Leadership in the Era of Artificial Intelligence.

Letter: The Urgency of Neurosurgical Leadership in the Era of Artificial Intelligence.

Comprehensive computational study in the identification of novel potential cholesterol lowering agents targeting proprotein convertase subtilisin/kexin type 9

The enzymatic target proprotein convertase subtilisin/kexin type 9 (PCSK9) is critically involved in the regulation of the lipoprotein metabolism leading to the degradation of low-density lipoprotein receptors (LDLRs) upon binding. Drugs that lower LDL cholesterol (LDL-C) through the inhibition of PCSK9 are useful in the management of hypercholesterolemia which greatly reduces the associated risk of atherosclerotic cardiovascular disease (CVD). In 2015, anti-PCSK9 monoclonal antibodies (mAbs), alirocumab and evolocumab were approved but owing to their high costs their prior authorization practices were impeded, reducing their long-term adherence. This has drawn considerable attention for the development of small-molecule PCSK9 inhibitors. In this research work, novel and diverse molecules with affinity towards PCSK9 thereby having ability to lower cholesterol. A hierarchical multistep docking was implemented to identify small molecules from chemical libraries with a score cutoff −8.00 kcal/mol, thereby weeding all the non-potential molecules. A set of seven representative molecules Z1139749023, Z1142698190, Z2242867634, Z2242893449, Z2242894417, Z2242909019, and Z2242914794 have been identified from a comprehensive computational study which included assessment of pharmacokinetics and toxicity profiles and binding interactions along with in-depth analysis of structural dynamics and integrity using prolong molecular dynamics (MD) simulation (in-duplicate). Furthermore the binding affinity of these PCSK9 inhibitory candidates molecules was ascertained over 1000 trajectory frames using MM-GBSA calculations. The molecules reported herein are propitious candidates for further development through necessary experimental considerations. Communicated by Ramaswamy H. Sarma

Prior authorizations for oral anticancer drugs and delayed prescription fills.

1504 Background: Oral anticancer drugs have proliferated in recent decades. These drugs are increasingly approved based on provisional data via the FDA’s accelerated approval pathway and have high prices, motivating payers to closely monitor how they are used. We assessed use of prior authorization (PA) of oral cancer drugs for Medicare Part D beneficiaries and assessed the impact of PA on delays in prescription fills. Methods: Using Medicare Part D formulary and claims data from 2010-2019, we described trends in Part D plans’ use of PA for oral oncology drugs, identified using the Oncology Care Model drug list (excluding hormonal therapies). We then examined changes in access to imatinib after the introduction of a new PA. We focused on imatinib because it is a highly effective first-in-class drug with a generic entrant in 2016. We compared Part D beneficiaries continuously enrolled in a plan with a policy change (new PA introduced) or a control plan (no change) in the 120 days before and after the policy change or equivalent date (control) and had at least three 30-day imatinib fills in the pre period. This restriction aimed to identify individuals filling regularly and plausibly expected to continue the drug. For each index fill in the post period, we calculated predicted fill (date of previous fill + days supply received). Our outcome variable was the difference (in days) between predicted and observed index fill date, censored at 120 days for post-period observations without an observed fill. We used an event study to model predicted vs. actual time to first fill following a policy change (new PA) relative to the controls (no change), adjusting for patient age, sex, low-income subsidy, average number of days between pre-period fills, year of fill, and plan type (standalone or Medicare Advantage). Results: The proportion of oral anticancer drugs requiring a PA increased from 52.8 to 96.3% from 2010 to 2019. For imatinib, PA increased from 65% to 89% from 2010-16, the year generic imatinib entered. PA for generic imatinib was 95% on market entry. In the imatinib event study sample, there were 1,354 index fills for patients. Unadjusted mean delay in index fill was 40 days for new PA and 15 days for controls; median difference was 4 and 3 days, respectively. Discontinuation was comparable: 9.3% (new PA) vs. 9.5% (control). The adjusted difference between predicted and actual fills for new PA was 20.3 days (95% CI 6.5-34.2, p&lt;0.004). Conclusions: Use of PA for oral oncology drugs has increased substantially over 10 years. In the setting of high prices and provisional outcomes data, PA may be appropriate. However, PA may delay fills, even for high-value drugs like imatinib. Oral anticancer drug adherence is an NCI priority; further study is warranted to identify opportunities to reduce administrative burden of PA and lessen barriers in access to effective medications.

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

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 &gt; .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 &lt; .001) and was significantly correlated with time spent on PA (ρ = .16, p = .04) and overall PA experience (ρ = .34, p &lt; .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 &lt; .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.

Better together: A team-based approach to improve prior authorization efficiencies and wellness in physicians and advanced care providers.

e13664 Background: The burden of prior authorizations (PAs) required for costly oncologic treatments is high. Upon PA denials, peer-to-peer requests are performed. These requests consume time and effort of physicians and advanced care providers (APPs) contributing to burnout and may have a negative impact on patient care. We aimed to assess the degree to which the PA process contributed to burnout among oncology clinicians prior to implementation of a new streamlined workflow aimed at improving clinician wellness. Methods: A baseline wellness survey was sent to all hematology-oncology faculty and APPs at the largest clinical site of our academic cancer center. Burn out, our primary outcome, was measured using the work-related Copenhagen Burnout Inventory. We included selected questions from the American Medical Association (AMA) surveys regarding physician perceived impact of PAs on clinical workload and care delivery. We asked physicians and APPs to rate the impact of PAs on burnout on a scale of 0-100. Analysis was conducted using descriptive statistics. This study was sponsored by our Office of Well-Being and Resilience. Results: The wellness survey was completed by 35 physicians and 21 APPs with a response rate of 53% in both. The median Copenhagen burnout score for physicians was 46.43 (35.71-60.71) with higher burn out scores among those identifying as females, in practice less than 15 years and with more than 60% time in direct patient care. The median burn out score for APPs was 64.28 (50-83.03). Similar to physicians, APPs with less clinical experience had higher burn out scores. When asked about the impact of PAs on burnout on a scale of 0-100, physicians at the main site reported a median of 13.5, while APPs reported a median of 53.5. Conclusions: Physicians and APPs report noteworthy baseline rates of burnout and dedicate a significant portion of the week to completing PAs. Importantly, APPs perceived the PAs to have a high impact on their burn out compared to physicians. We will use these data to determine the efficacy of a new process that utilizes a single EMR platform for finance and cancer registry teams to abstract and document all of the required elements to streamline the PA process for intravenous/injection cancer treatments with the goal to reduce the number of PAs and improve wellness. [Table: see text]