Strategic Operational Redesign Improves Prior Authorization Access: A Validation Study.

Area of Science:

• Oncology
• Radiation Oncology
• Health Services Research

Background:

• Prior authorization (PA) presents a significant administrative burden in oncology, particularly for radiation oncology.
• Delays in PA can impede patient access to timely cancer treatment.
• There is a need for effective strategies to streamline the PA process and improve patient care.

Purpose of the Study:

• To describe the impact of a novel operational PA redesign on authorization time and patient access to cancer care.
• To evaluate the replicability and adoptability of this PA redesign strategy across oncology centers.
• To assess the effectiveness of a 3-tiered approach to PA in radiation oncology.

Main Methods:

• A 3-tiered PA redesign strategy was implemented, focusing on payor accountability, leveraging insurance expertise, and updating internal procedures.
• Key metrics, including approval rates, patient treatment proportions, and authorization times, were compared at three time points: pre-intervention, phase-in, and post-intervention.
• Provider burden and patient care improvements were assessed through surveys.

Main Results:

• Commercial proton beam therapy approvals increased by 30.6% post-intervention (P < .001).
• The proportion of commercially insured patients treated with proton therapy rose by 6.2%, with new patient starts increasing by 11.7 patients/month.
• Median authorization time decreased to 1 week, and 90% of providers reported reduced PA burden and improved patient care.

Conclusions:

• This study presents the first validated operational strategy to improve cancer therapy access while reducing PA burden.
• The novel approach, based on PA regulations across disciplines, shows promise for addressing access barriers in medical and surgical oncology.
• The redesign demonstrates potential for adoption in other oncology settings to enhance patient care and operational efficiency.