Insurance prior authorization requirements are creating significant barriers to optimal cancer care delivery, forcing oncologists to navigate complex appeals processes that can delay treatment by up to two weeks and sometimes result in suboptimal therapeutic decisions, according to Coral Omene, MD, PhD, associate professor at Robert Wood Johnson Medical School and Rutgers Cancer Institute.
Treatment Delays Impact Patient Outcomes
The appeals process for cancer drug approvals varies considerably in duration, ranging from several days to over two weeks. For patients with aggressive malignancies requiring immediate intervention, these delays can be particularly detrimental to outcomes.
"If someone has an aggressive disease that you need to start treatment right away, they don't have a week, a week-and-a-half to get this [treatment approved]," Omene explained. The lengthy approval process sometimes forces providers to abandon their original evidence-based treatment plans and pivot to alternative regimens that may not represent the optimal first-line option for the patient.
Administrative Burden Affects Care Quality
When attempting to deliver quality care based on evidence-based guidelines, oncologists frequently encounter multiple administrative hurdles and approval steps for drugs that should be readily approved for appropriate patients. The disconnect between clinical guidelines and insurance company algorithms creates additional complexity in the approval process.
"Sometimes we have to go through so many steps and appeals processes because the guidelines or the algorithms used may be somewhat different based on what the insurance companies may be using for their own delivery of care," Omene noted. This administrative burden proves "very, very taxing on not only the patients, but the providers and the health care system as a whole."
Psychological Impact on Patients and Providers
The insurance approval process creates significant anxiety for both patients and healthcare providers. Patients experience stress while waiting for treatment approval, while providers feel frustrated by their inability to immediately deliver indicated care. This psychological burden compounds the already challenging experience of cancer diagnosis and treatment.
Redefining Value in Cancer Care
Traditional value metrics in oncology focus on clinical endpoints like overall survival and progression-free survival. However, Omene emphasized that true value should incorporate quality-of-life measures specific to individual patients. Real-world data and analytics are crucial for understanding value and tracking intervention impacts, though not all practices have the resources to collect and analyze such comprehensive data.
Disparities in Value-Based Care Implementation
Value-based care models may inadvertently exacerbate existing healthcare inequities. The administrative burden of data collection and reporting can strain limited resources in underserved communities, potentially diverting attention from direct patient care. This creates a risk of self-selection, where patients with greater financial resources or easier access to care receive priority.
"Then, people who cannot [pay more] may have to be traveling longer distances to get care where they can, and...if transportation is already a problem, it goes on, and it's like a vicious cycle," Omene explained. "You can see how it can sort of permeate in ways that are unintended but can easily happen depending on the setting."
Technology Solutions for Access Improvement
Technology offers potential solutions for improving cancer care access, particularly for remote or underserved communities. Telemedicine expansion beyond its pandemic-era growth could enhance clinical trial access for patients unable to travel to major cancer centers. Virtual consultations and electronic consent processes could eliminate additional in-person visits for trial enrollment.
"[We should] think about how we can leverage some of these avenues that we use in recent years to better get high-tech care to these patients," Omene suggested.
Social Determinants Integration
Addressing healthcare disparities requires incorporating social determinants of health into value-based care models. Factors such as transportation access, housing security, and geographic proximity to care facilities significantly impact treatment outcomes and must be considered in comprehensive care delivery.
"Gathering this information helps one to target these patients appropriately [and] intervene with resources that are needed to be able to carry out the care in this value-based way," Omene emphasized.
