Studies Highlight Barriers of Drug Costs and Prior Authorizations

September 3, 2019

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ASCO Perspective

“The high costs of cancer care have many facets that often result in barriers to accessing timely and consistent care,” said Neeraj Agarwal, MD, ASCO expert and member of the Quality Care Symposium News Planning Team. “High out-of-pocket drug costs, shown here with oral anti-cancer drugs, is associated with a lower number of prescriptions, shorter duration of therapy, and inferior cancer-associated outcomes. Another aspect is the administrative burden seen in one study that finds a vast majority of prior authorizations are redundant, and a close collaboration between hospitals and insurers can help eliminate them and improve efficiencies in health care systems.”


ALEXANDRIA, Va. – Drug costs and requirements for prior authorization of treatment plans pose barriers to cancer treatment and can potentially affect outcomes for many patients, according to two studies that will be presented at the American Society of Clinical Oncology’s (ASCO) upcoming Quality Care Symposium, taking place September 6-7, 2019, at the Hilton San Diego Bayfront in San Diego.

As the nation grapples with the high costs of cancer care, two new studies explore varying aspects of these costs. The studies respectively examine how the high out-of-pocket costs for oral cancer therapy impact overall survival rates and demonstrate how a successful collaboration between a health system and a commercial payor can streamline the prior authorization process and get patients into treatment more quickly. Authors will present their findings at the American Society of Clinical Oncology’s (ASCO) upcoming Quality Care Symposium, taking place September 6–7, at the Hilton San Diego Bayfront in San Diego.

Following is a summary of each of the two major studies related to the cost of care.

Out-of-Pocket Costs for Certain Drugs May Limit Treatment and Reduce Survival

[Summary includes updated data from abstract]

Researchers from Fred Hutchinson Cancer Research Center in Seattle found that the out-of-pocket (OOP) cost of oral tyrosine kinase inhibitor drugs (TKI) were not only linked to a lower number of these prescriptions and shorter duration of therapy, but also were associated with poorer survival in patients with advanced non-small cell lung cancer (NSCLC) with certain tumor genomic mutations. Oral TKIs are an effective treatment for these patients but are costly.

The study included 106 patients with stage-IV NSCLC identified from the Washington State Surveillance, Epidemiology and End Results (SEER) registry. These patients had mutations of epidermal growth factor receptor (EGFR+) and anaplastic lymphoma kinase (ALK+) genes. Data from the registry was paired with claims data. To be included, patients had to have at least one prescription for an oral TKI. The researchers calculated median OOP TKI costs for the first three months of therapy. Patients were categorized into four groups (quartiles) based on these costs.

Based on a multivariate analysis, the researchers found that the quarter of patients in Washington state with the highest median OOP costs were more than twice as likely to die after 3 months of starting TKI treatment (adjusted hazard ratio, 2.31; p=0.003) compared with all other patients in the study (updated data).

“Patients paying the highest out-of-pocket costs for TKIs have a greater risk of death,” said lead author Bernardo H. L. Goulart, MD, MS, who is a medical oncologist and outcomes researcher at Fred Hutchinson. “If we can confirm the results with a larger nationwide sample, the findings help to make the case for a review of Medicare coverage for these effective medications.

The results will need to be confirmed in a larger nationally representative sample before firm conclusions can be drawn. The researchers are planning such a study.

View the full abstract.

Prior Authorizations Are Often Unnecessary; Cooperating with Commercial Payors to Eliminate Prior Authorizations Reduced Administrative Burden

In another study to be presented at the meeting, researchers with the Seattle Cancer Care Alliance (SCCA) found that the vast majority of prior authorizations (94.8%) for imaging studies were approved instantly or after the provision of additional information. The findings led the Alliance to partner with a large regional commercial payor to eliminate the need for prior authorizations.

“While prior authorizations are intended to ensure medical necessity, these additional requirements can add to administrative burden,” said lead author Mallika Sharma, MPH, who is a quality and value analyst at Seattle Cancer Care Alliance. “In some cases, the process can even cause significant delays for patients, increasing their anxiety and diminishing quality of life.”

After reviewing imaging requests, the researchers found that 94.8% of prior authorizations were approved instantly or after providing more documentation, 2.15% of requests were approved after a peer-to-peer review, and only 3% of prior authorizations did not meet medically necessary criteria.

Given these findings, the SCCA worked with a large commercial payor to eliminate prior authorizations for all imaging requests (excluding Positron Emission Tomography (PET) and PET/computerized tomography (CT)). As part of this agreement, all ordering clinicians were required to complete training on Imaging Appropriate Use Criteria from the National Comprehensive Cancer Network (NCCN). Internal audits showed that the Alliance achieved 100% compliance.

“SCCA uses an in-house tool to support clinical decision making,” said principal investigator Tracy Wong, MBA. “However, most EHRs have the capability to embed clinical decision support that aligns with payers’ medical coverage policies, making this a relatively simple and scalable way to speed and improve care. This is what payers are asking for: the ability for providers to access the most up-to-date, evidence-based practice guidelines in real-time.”

View the full abstract.

This year’s Quality Care Symposium will include more than 320 abstracts focusing on efforts to improve the quality of care for patients with cancer. On-site facilities for reporters will include a working newsroom and access to leading experts in quality care.

Information for Media: www.asco.org/QCSpresskit

Doctor-approved patient information for your readers from Cancer.Net:

2019 Quality Care Symposium News Planning Team

  • Chair: Merry-Jennifer Markham, MD, FACP, University of Florida
  • Randall J. Kimple, MD, PhD, University of Wisconsin
  • Neeraj Agarwal, MD, Huntsman Cancer Institute- University of Utah Health Care

View the disclosures for the News Planning Team.

View additional abstracts on the Tip Sheet.

ATTRIBUTION TO THE 2019 QUALITY CARE SYMPOSIUM IS REQUESTED IN ALL NEWS COVERAGE.

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About ASCO: 

Founded in 1964, the American Society of Clinical Oncology, Inc. (ASCO®) is committed to making a world of difference in cancer care. As the world’s leading organization of its kind, ASCO represents nearly 45,000 oncology professionals who care for people living with cancer. Through research, education, and promotion of the highest-quality patient care, ASCO works to conquer cancer and create a world where cancer is prevented or cured, and every survivor is healthy. ASCO’s Conquer Cancer Foundation supports the Society by funding groundbreaking research and education across cancer’s full continuum. Learn more at www.ASCO.org, explore patient education resources at www.Cancer.Net, and follow us on Facebook, Twitter, LinkedIn, and YouTube.