Economic Impact of Anti-Vascular Endothelial Growth Factor Prior Authorization Process From a Large Electronic...

Area of Science:

• Health Economics
• Ophthalmology
• Health Policy

Background:

• Prior authorizations (PAs) are administrative hurdles for accessing treatments.
• Anti-vascular endothelial growth factor (anti-VEGF) therapies are crucial for managing retinal diseases.

Purpose of the Study:

• To quantify the economic impact of insurance prior authorizations (PAs) for anti-VEGF therapies on society.
• To analyze the cost-effectiveness of the PA process for anti-VEGF treatments.

Main Methods:

• Analysis of PA denial and delay rates from a large electronic database (SamaCare PA).
• Utilized a theoretical cost-effectiveness model to calculate increased societal costs associated with PAs.
• Estimated costs in 2025 U.S. dollars.

Main Results:

• Prior authorizations (PAs) increased total societal costs by $10,842.24 per patient lifetime.
• The PA process added $637.78 per request, with minimal savings from denials ($27.11 per injection).
• PAs were not cost-saving in over 99.9% of scenarios, increasing costs for workplaces, patients, and providers, while insurers saw minimal gains.

Conclusions:

• Prior authorization requests for anti-VEGF therapies are approved in 97.7% of cases but are delayed in 97.9%.
• The PA process is not cost-saving and significantly elevates the total societal costs of anti-VEGF treatments.
• Insurance companies were the only entities to potentially benefit financially from the PA process.