OBR OncologyHuge Spike in Prior Authorization for Cancer Drugs Leaves Docs “Shouting in the Wind”

Surge in Prior Authorization for Oral Oncology Drugs Reflects Growing Role of Insurers in Cost Control

A recent study in JAMA reveals a significant uptick in utilization management, particularly prior authorization, for oral oncology drugs covered under Medicare Part D between 2010 and 2020. This analysis is crucial in the backdrop of increasingly high costs for novel cancer medications and pinpoints insurers as the key players in managing these costs.

HCN Medical Memo
The study serves as a stark reminder of the growing complexity and administrative burden in prescribing oral anticancer medications. Insurers are increasingly becoming the gatekeepers, with prior authorization almost ubiquitous. Understanding this landscape can better prepare healthcare providers in navigating these challenges and advocating for effective and timely patient care.

Key Points:

• Significant Increase in Prior Authorization: The proportion of Medicare Part D oral anticancer drugs requiring prior authorization jumped from 52.8% in 2010 to 96.3% in 2019.
• Expert Commentary: Ravi B. Parikh, MD, MPP, suggests that the increase in prior authorization is unsurprising given the role of insurance companies as cost controllers.
• Other Utilization Management Tools: Although prior authorization dominates, other tools like step therapy and quantity limits are also being utilized. Step therapy is used in less than 1% of cases, while the proportion of specialty brand drugs requiring quantity limits rose from 31.4% in 2010 to 62.5% in 2020.

Additional Points:

• Growth in Medicare Beneficiaries: The number of Medicare Part D beneficiaries increased from 28 million in 2010 to more than 47 million in 2020.
• Increase in Specialty Generic Drugs: Prior authorization for specialty generic drugs increased from 91.1% in 2016 to 95.0% in 2020.
• Legislative Efforts: Although there are initiatives to reduce the burden of utilization management, little progress has been made in reforming the system according to experts.

“I think the more that we could be involved in helping the problem, the less of a burden prior authorization could play. And I think that’s a tradeoff that most oncologists would be willing to accept.”
– Ravi B. Parikh, MD, MPP, Medical Oncologist, University of Pennsylvania and the Corporal Michael J. Crescenz VA Medical Center in Philadelphia

More on Medicare