Oncologists Say Prior Authorization is Out of Control and Harming Patients With Cancer

The Community Oncology Alliance (COA) has submitted formal comments to the Centers for Medicare & Medicaid Services (CMS) on a proposed rule for streamlining the prior authorization process. In the comments, COA notes that prior authorizations by insurers in Medicare Advantage and commercial plans are out of control. As a result, patients with cancer and the providers that treat them are forced to suffer inhumane and inane barriers to optimal care.

Rather than being used by insurers to ensure proper treatment and control waste, prior authorizations – along with “fail first” step therapy and other “utilization management” tactics – are being used to control costs. The result is that prior authorizations end up being bureaucratic roadblocks that simply delay or deny Americans with cancer from getting the treatment their providers prescribe. Furthermore, community oncology care teams are forced to waste valuable resources with ridiculous and time-consuming prior authorizations, oftentimes for routine and evidence-based care, and engage in discussions with insurer medical staff that have no background in cancer treatment, let alone in the latest treatments and therapies.

In the comment letter COA notes its appreciation for CMS’ goal of reducing the prior authorization burden and support for the proposed rule but is extremely concerned that it excludes drugs. Any effective, comprehensive regulatory initiative to streamline the current onerous prior authorization process must include drugs which are a critical aspect of cancer treatments.

As a more comprehensive solution to the broken prior authorization system, COA suggests that CMS implement a “gold card” program for prior authorizations, which should include drugs, in Medicare Advantage. “Gold card” programs allow physicians that have a high amount of prior authorization approvals to bypass these requirements for a certain period. This simple solution has been recently adopted in states and could represent a straightforward way to address overutilization and abusive prior authorization requirements.