Treatment Delays Associated With Prior Authorization for Infusible Medications: A Cohort Study

Abstract

Objective. Prior authorizations (PAs) are commonly used by insurers as cost-containment strategies for expensive medications, including infused biologics. There is scarce data about the effect of PA requirements on patient-oriented outcomes. Methods. We included patients for whom an infusible medication was prescribed for a rheumatologic condition. The exposures of interest were a PA requirement and whether or not the PA was denied. The primary outcome was the difference in days from medication request to infusion. Secondary outcomes included the proportion of denied PAs and differences in glucocorticoid exposure following a PA request. Results. Of the 225 patients, the infusible medications of 160 (71%) required a PA. PAs were associated with a greater number of days to infusion compared to cases in which no authorization was required (median 31 days [interquartile range (IQR) 15-60 days] versus median 27 days [IQR 13-41 days]; P = 0.045), especially among the 33 patients (21%) whose PA was denied initially (median 50 days [IQR 31-76 days] versus median 27 days [IQR 13-41 days]; P < 0.001). PA denials were associated with greater prednisone-equivalent glucocorticoid exposure in the 3 months following the request than when a PA was not required (median 605 mg [IQR 0-1,575] versus median 160 mg [IQR 0-675]; P = 0.01). Twenty-seven of the 33 PA requests that were initially denied (82%) were eventually approved. Thus, 96% of all PAs were ultimately approved. Conclusion. PA requirements are associated with treatment delays and denials are associated with greater glucocorticoid exposure. Because the great majority of PA requests are ultimately approved, the value of PA requirements and their impact on patient safety should be reevaluated.

Beyond Being Insured: Insurance Coverage Denial as a Major Barrier to Accessing Care During Pregnancy and Postpartum

“…Our analysis showed that individuals who experienced insurance coverage denial reported amplified challenges to accessing care both during pregnancy and postpartum. These associations are consistent with previous reports that insurance issues were associated with delays in care in general ( Wallace et al, 2020 ; Wilcox et al, 2016 ). The lingering associations of insurance coverage denial on delaying care during and after pregnancy were noteworthy.…”

Prior Authorization Requirements and Prescription Fill Patterns Among Patients With Heart Failure

“…In this study of patients with heart failure, we found that prior authorization requirements were associated with increases in time until and decreases in likelihood of prescription fill within 365 days. Our findings are consistent with similar studies in other clinical settings, 8 including oncology, 18 rheumatology, 19 , 20 , 21 and gastroenterology, 22 as well as investigations of region-wide changes in prior authorization policies, 23 , 24 , 25 which also showed similar associations between these requirements and decreases or delays in treatment. Our study expands on this existing literature by redemonstrating this barrier in a contemporary, U.S.-based cohort for 2 mortality-reducing medications used to treat heart failure, a common and highly morbid condition that has a 5-year mortality of 40% to 60%.…”

What Is the Impact of Prior Authorization on the Incidence of Pediatric Tonsillectomy?

“…In the years following implementation of PA, just 1.5% of all claims for tonsillectomy were denied approval. Our findings are similar to those of other studies that demonstrate very low denial of PA claims (<4%) for elective surgery, prescription medications, and imaging studies 13,15–17 . Furthermore, no statistically significant reduction in the incidence of tonsillectomy was discovered after implementation of PA for government plans alone, commercial plans alone, or all plan types combined.…”

“…Our findings are similar to those of other studies that demonstrate very low denial of PA claims (\4%) for elective surgery, prescription medications, and imaging studies. 13,[15][16][17] Furthermore, no statistically significant reduction in the incidence of tonsillectomy was discovered after implementation of PA for government plans alone, commercial plans alone, or all plan types combined. The overall very low percentage of claims denied and subsequent lack of a reduction in the incidence of tonsillectomy raise the question of whether PA is effective in eliminating overuse of health care resources and thereby decreasing associated over expenditure.…”