While improvement in cancer outcomes has been realized in the last decade, these advances have come at the expense of increasing the cost of therapy.[1] Cancer has risen to be one of the costliest medical conditions with single medication prices often exceeding $10,000 per month.[2] Consequently, prior authorization has been more ubiquitously applied to all aspects of cancer care to ensure that new, expensive therapies are utilized appropriately.

The Center for Medicare and Medicaid Services (CMS) recently announced they are truncating the decision time frame for Part B drugs to mirror that of Part D. Effective January 1, 2020, Part B drugs, including those subject to step therapy, will adhere to decision time frames of 72 hours for standard determinations and 24 hours for expedited determinations.[3] CMS states it is their “intent to balance goals of cost savings and efficiencies with enrollee access, enhanced quality of care, and due process protections.”[3] By aligning Part B and Part D adjudication times, it “establishes greater clarity and consistency in the coverage determination and appeals processes across the two programs.”[3]

There is still significant room for improvement in prior authorization, as evidenced by survey findings released last year by the American Medical Association, which quantified that about 20% of patients wait 3-5 days for the results of their prior authorizations and an additional 7% wait more than 5 days.[4] This is significant given that each week of delay is associated with a 1.2%-3.2% increased risk of death.[5]

With the rising cost of cancer care and new determination timeframes established by CMS, how can health plans keep pace and make swift evidence-based determinations?

Keep Pace with Oncology Analytics
A recent Journal of Oncology Practice editorial demonstrated that many oncology reviewers for prior authorization processes do not have any oncology experience.[1] Oncology Analytics only employs board certified medical oncologists, hematologists and radiation oncologists, assuring your providers will speak to a true peer. We can provide your health plan with real-time oncology expertise as an extension of your internal teams, for a fraction of the cost of doing it yourself, and help you keep pace with the adjudication time frames for oncology prior authorizations.

Our comprehensive approach addresses the in-house resource constraints most health plans face with keeping pace, such as:

  • e-Prior Authorization. Purpose-built for oncology, Oncology Analytics’ e-Prior Authorization solution reduces the administrative burden for providers and expedites the review and decision process. Our e-Prior Authorization solution is an easy to use web application designed to facilitate immediate approval for treatment submissions that align with evidence-based guidelines and protocols from nationally recognized authorities such as NCCN, ASCO, and others.
  • Real-time Oncology Expertise. For complex patient cases, our Clinical Oncology Team facilitates oncologist-to-oncologist reviews, where treating oncologists can engage in discussions of patient cases with Oncology Analytics’ board-certified oncologists, radiation oncologists, hematologists, and pharmacists. This process ensures that the recommended therapy is the most efficacious, affordable, least toxic, and provides the best evidence-based potential outcome.

Oncology Analytics understands the complexity involved in the management of cancer treatment options caused by the rapid pace of research and new drug introductions that are introduced on a daily basis. We are committed to the ongoing review and analysis of oncology treatments, their outcomes, and adverse effects to ensure that all cancer treatment recommendations provide patients with the opportunity to achieve the best possible outcome.

If you would like to contact one of our oncology specialists to discuss strategies to help your organization Keep Pace with new and emerging cancer treatments, please click here.

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[1] Lin, N. U., Bickhoff, H., & Hassett, M. J. (2018, September). Increasing Burden of Prior Authorizations in the Delivery of Oncology Care in the United States. Journal of Oncology Practice, 14(9), 525-529.

[2] Financial Toxicity and Cancer Treatment (PDQ) – Health Professional Version. (n.d.). Retrieved from National Cancer Institute: https://www.cancer.gov/about-cancer/managing-care/track-care-costs/financial-toxicity-hp-pdq

[3] Modernizing Part D and Medicare Advantage To Lower Drug Prices and Reduce Out-of-Pocket Expense. (2019, May 23). Retrieved from https://www.federalregister.gov/documents/2019/05/23/2019-10521/modernizing-part-d-and-medicare-advantage-to-lower-drug-prices-and-reduce-out-of-pocket-expenses

[4] 2018 AMA Prior Authorization (PA) Physician Survey. (2018). Retrieved from American Medical Association: https://www.ama-assn.org/system/files/2019-02/prior-auth-2018.pdf

[5] Prior Authorization and Cancer Patient Care. (2019, April). Retrieved from https://www.astro.org/ASTRO/media/ASTRO/News%20and%20Publications/PDFs/ASTROPriorAuthorizationPhysician-SurveyBrief.pdf

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