Strategic Operational Redesign for Successfully Navigating Prior Authorization Barriers at a Large-Volume Proton Therapy Center

PURPOSE:

Prior authorization (PA) can be a resource-intensive barrier to oncologic care. To improve patient access and reduce delays at our large, academic proton therapy center, we implemented a novel payor-focused strategy to efficiently navigate the PA process while eliminating physician burden and reducing inappropriate denials.

METHODS:

In 2017, business operations were redesigned to better reflect the insurance process: (1) certified medical dosimetrists (CMDs), with their unique treatment expertise, replaced our historical PA team to function as an effective interface among physicians, patients, and payors; (2) a structured, tiered timeline was implemented to hold payors accountable to PA deadlines; and (3) our PA team provided administrative leadership with requisite insurance knowledge. PA outcomes were compared 6 months before and after the intervention.

RESULTS:

After implementation of this multifaceted strategy, the median time to successful appeal (after initial denial of coverage) decreased from 30 to 18 days (P < .001), and the total number of overturned denials increased by 56%. Because of the efficiency of the CMDs, full-time equivalents on the PA team actually decreased by 44%, translating to a 34% reduction in team personnel expenses. Internal referrals increased by 29%, attributable to optimized communication and diminished administrative burden for providers. New treatment starts also increased, resulting in a 37% larger patient census on treatment.

CONCLUSION:

Incorporating payor-focused strategies can improve patient access in a cost-effective manner while decreasing time and administrative burden associated with the PA process. These operational concepts can be adapted for other oncologic practice settings facing analogous PA-related obstacles.

INTRODUCTION

Prior authorization (PA) is a growing national problem affecting timely patient access to care across medicine.^1-7 Within the field of oncology,⁷ > 90% of surveyed physicians reported delays in their ability to provide therapy because of PA-related impediments, and one-third of providers had to abandon treatment altogether for one or more patients.⁸ These PA-related burdens are particularly onerous for patients awaiting curative oncologic treatments, such as radiation therapy.

Proton beam therapy (PBT), a highly specialized form of radiotherapy with the potential to spare normal tissue and thus minimize toxicity, has been adversely affected by these concerns. The increasing adoption of PBT has amounted to > 70 proton therapy centers (PTCs) worldwide,^9-11 with nearly half in the United States^12,13 and anticipation for continued growth of this advanced technology in coming years.^14-16 Yet numerous PTCs have failed operationally¹⁷—and many patients have been denied PBT—because of increasingly restrictive coverage policies that persist in the face of evidence supporting PBT use.¹⁷ Ironically, insurance denials are a major contributor to the lack of level 1 evidence for PBT, because the trials required to generate such data cannot accrue owing to lack of coverage.^9,18,19

However, PBT does not stand alone (Data Supplement).^10,11,20 Restrictive coverage policies can also serve as barriers to patient access for novel systemic therapies, cutting-edge molecular testing, and even supportive care services for cancer patients.²¹ Although the PA process is intended to represent a safeguard for inappropriate treatments,²⁰ studies have demonstrated that nonclinical variables—notably, insurance type—may ultimately yield greater influence on insurance outcomes than clinically relevant factors.^10,11 Such inexplicable findings raise questions about the true impact of the PA process in the current health care climate, other than serving as a barrier to timely treatment.^{5,9,10,20,22,25}

Recognizing these concerns, our PTC successfully implemented an operational strategy aimed at addressing PA-related barriers for our patients. The key concepts underlying our approach can be adapted for other oncologic practice settings to benefit patients and providers in timely, evidence-based treatment delivery.

METHODS

In 2017, our PTC launched a multifaceted initiative to optimize patient access to care (Fig 1). This included (1) restructuring our PA team with uniquely equipped personnel; (2) providing new executive leadership with the requisite insurance knowledge; and (3) deploying a selective tiered system for authorization responses by payors.

Fig 1.

Strategic initiative to decrease delays and improve access to proton therapy. APD, advanced practice dosimetrist; IRO, independent review organization; P2P, peer-to-peer; PA, prior authorization.

PA Team Redesign

We replaced our historical team of registered nurses (RNs) with clinical medical dosimetrists (CMDs) to aid communication among patients, physicians, and payors. Although RNs and advanced practice providers (APPs) certainly benefit from clinical training and direct patient care experience, CMDs have a clear educational advantage with respect to radiotherapy treatment planning, thereby facilitating easy navigation of the PA process specific to PBT.^27,28 The CMD curriculum, tailored to Radiation Oncology, encompasses courses in radiobiology, physics, and treatment planning (Appendix Fig A1, online only). This relevant and highly specialized education uniquely positions CMDs in formulating evidence-supported strategies to obtain authorization and successful appeals.

To this end, our center hired 4 experienced CMDs to replace our historical PA team staff and work full time as advanced practice dosimetrists (APDs). In this administrative role, our APDs functioned independently on PA process rebuttals and directly helped patients, payors, and providers navigate through the multilayered PA process, thus reducing the administrative effort burden on clinical teams. The APDs also retain their clinical dosimetric experience, allowing them to generate comparative plans when requested for payors, further supporting their inherent value within this advanced role.

Requisite Payor Knowledge and Experience

To educate and prepare our newly restructured team, our PTC hired and provided a medical executive with extensive firsthand experience in the insurance authorization process to replace the prior PA team manager. Within this new leadership position, our newly appointed chief health care value officer (CHVO) helped with strategy development and implementation, guiding our PTC through the complex modern payor landscape and helping our teams adapt rapidly to payor policy changes as needed.

Notably, the CHVO provided individualized training to our APDs on PA submissions, appeal letters, legalistic rebuttals, document formatting and submission, peer-to-peer scripts, and personalized, evidence-based appeal letters (Appendix Fig A2, online only). Our APDs received a crash course on relevant payor rules and regulations, allowing our staff to hold third parties accountable throughout the PA and appeals timeline. For example, the legally stipulated response time per appeal request generally falls within 15 days from submission,^29,30 and our APDs vigilantly held payors accountable to deliver within these deadlines and minimize unnecessary treatment delays associated with pending authorization decisions for our patients with cancer.

Selective Tiered Authorization and Appeal Process

To support these strict deadlines, a tiered structure, in the form of an automated electronic system, was implemented to keep track of authorization responses and ensure timely navigation of appeal steps (Fig 1). The basic premise of the tier was built around national and state mandates on maximum response times for payor responses at each authorization step,^29-31 which are not often advertised (Data Supplement). In recent months, several states have proposed legislature that will regulate the turnaround time of payor determinations throughout the PA process.^32,33 This system was tailored to payor-specific factors, including strategic bypass of late sequential-appeal steps directly toward independent external review, when indicated, and was constantly updated as new legislation was passed. Holding payors accountable to the most up-to-date legislation is critical to minimize treatment delays associated with the PA process.

Analysis

We compared operational metrics 6 months before (October 2016-March 2017) and 6 months after (October 2017-March 2018) implementation of this strategic model, accounting for the expected ramp-up phase between these intervals for orientating and restructuring purposes (Fig 2). Time to insurance approval was computed in calendar days from the date of initial authorization inquiry, through the appeal process, to the date of final determination. Differences in time to authorization among the preintervention and postintervention groups were compared via the Mann-Whitney test. Pearson χ² test was used to compare overall approval rates (and proportion of cases appealed) among different disease sites, including pediatric care as a category. For all analyses, the threshold for statistical significance was P < .05.

Fig 2.

Timeline and phase-in of the strategic initiative intervention. Admin., administrative; APD, advanced practice dosimetrist; CMD, clinical medical dosimetrist; d, days; FY, fiscal year; MD, medical doctor; MLP, midlevel provider; PA, prior authorization; RN, registered nurse.

RESULTS

Authorization and Appeals

Over 18 months (October 2016-March 2018), 1,700 patients entered the insurance authorization process for PBT at our PTC. Of these, 1,266 (74%) were ultimately approved for treatment. Of the 633 initially denied coverage, 454 entered the appeal process, and denial was overturned for 199 patients (44%). Approval rates (with proportion appealed) varied significantly (P < .001) by disease site and pediatric care: pediatrics, 95% (3%); thoracic, 87% (13%); CNS, 80% (19%); GI, 77% (22%); head and neck, 70% (21%); genitourinary, 66% (16%); and breast, 66% (5%).

Operational Gains

Using this operational strategy, median time to approval decreased from 30 to 18 days after appeal, between the pre- and postintervention time periods (P < .001; Fig 3A). Overturned denials increased by 56% (52-81 per 6-month interval; Fig 3B), and internal referrals increased by 29% (342-442), which was attributable to improved communication and decreased administrative burden for providers (with our physicians conducting only 6% of all peer-to-peer communication in this postintervention era). New treatment starts also increased by 22 patients monthly, with a 37% (from 358 to 489) census increase noted (Fig 3C).

Fig 3.

(A) Decrease in delays (time) to approval; (B) improvement in denial overturns; (C) expanded overall patient census after the intervention.

APD Value

Because of the APDs’ specialized training and unique skill set, the average APD salary was 19% higher than that of historically used RNs on the PA team, implying greater cost per full-time equivalent (FTE). However, the superior ability of APDs to efficiently navigate the PA process justified this salary discrepancy: each full-time APD could simultaneously coordinate 20-40 PA/appeal requests, approximating the capacity of patients per treatment vault. On the basis of these metrics, our center hired 1 APD per gantry, plus an additional APD (total of 4) to account for volume fluctuations.

Personnel Expenses

Total FTEs on the PA team decreased by 44% after the intervention (from 9 to 5): 4 APDs plus 1 medical executive, who replaced the prior PA team manager. This 44% reduction in FTEs translated into a 34% decrease in personnel expenses associated with the new PA team, despite the increased APD salaries (+19% more than RN salary) and the relatively higher salary of our new medical executive (+21% more than the previous team manager). No losses were documented from an accounting standpoint, and our PTC appreciated significant reductions in administrative-related costs (due to decreased provider burden and treatment delays).

Despite the cost-saving reduction in personnel expenses, there were likely unmeasurable costs with hiring and training during the phase-in period. Yet both appeals and patient census grew during the phase-in period at a slower rate (Fig 2). Considering the average net revenue generated per patient at our PTC, we estimate that 10-13 new starts would justify the PA team expenses (break-even point), versus 15-16 new starts for the prior team structure. With respect to timing, the new PA team would justify its own expense 5-6 months from inception (despite phase-in), which is a conservative estimate based on the significant increase in appeals after inception (Fig 3).

DISCUSSION

To our knowledge, this is the first study to communicate a successful, evidence-based, payor strategy for improving patient access to PBT in the setting of a large-volume academic PTC. Throughout the field of oncology, the PA process can deny patients appropriate access to care.⁷ However, the concepts underlying our operational redesign may be implemented among other oncologic practice settings, for novel systemic therapies or technologically advanced surgical methods, to facilitate efficient navigation through the PA process and promote timely access to evidence-based cancer therapy.

Among our outcomes, the greatest success was the significant decrease in authorization time (and, thus, time to treatment). As numerous studies have demonstrated, minimizing time to curative treatment (eg, radiotherapy, chemotherapy, surgery) is vital for patients with cancer. Through this multifaceted strategic approach, we were able to treat more patients per time interval and to minimize administrative fatigue for patients and providers. Notably, these successes were achieved despite the increasingly restrictive payor policies that have evolved in recent years, particularly for PBT.^10,34

This study also supports the high-value proposition of restructuring a payor team to champion patient access to PA-burdened oncologic therapies, a concept that can be easily extrapolated outside of radiation oncology. Reports from other oncologic centers indicate that many practices maintain large PA teams to overcome administrative burden for providers and help facilitate patient access to various cancer therapies^5,21,35,36; according to a recent ASCO survey, the average oncologic PA team exceeds 6 FTEs.⁷ However, many of these PA teams likely lack the requisite clinical expertise to articulate a compelling argument for medical necessity and/or the requisite insurance knowledge to efficiently navigate through the multileveled PA process and its complicated timelines.

Regarding the requisite clinical expertise, our success with APDs suggests that PA teams can benefit from the administrative promotion of experienced care-team members with prior training to handle details specific to a given PA process. The nuanced expertise of such care-team members facilitates efficient navigation during payor negotiations. For example, subspecialized APPs may benefit medical or surgical oncology PA teams because these APPs have worked alongside their respective providers and thus understand the evidence, indications, and rationale required for successful peer-to-peer and appeal steps.

As for the requisite insurance knowledge, the same clinical care team members would also benefit from payor-specific education and formal training on appeal steps, imparting the requisite insurance knowledge necessary to efficiently navigate the PA process. As demonstrated by our phase-in period, the orientation process will initially require time and resources but will enable the PA team to operate independently without constant provider input. In turn, such training can lead to reduced administrative burden, decreased treatment delays, increased patient and provider satisfaction, and an overall high return on investment. At our PTC, the APDs have directly contributed to increased patient volume, along with cost savings from decreased personnel expenses.

Several limitations of this study may limit generalizability for other practice settings. Regardless of the medical specialty, we emphasize that for such a structural intervention to take place, a center’s executive leadership must remain cognizant of their limitations and strengths and be willing to invest in the appropriate infrastructure, personnel, and educational measures to successfully do so. Furthermore, although each pillar of this multifaceted strategy may provide some absolute benefit, we believe maximum success relies on synergy of all components working simultaneously within this comprehensive system redesign.

Potential confounders may also limit interpretation of these results. For example, some successes may have resulted from our PTC’s marketing activities, although marketing strategy was not altered throughout this intervention and would not affect the noted time reductions. Additional unaccountable factors may include major legislative changes regarding the PA process, leadership changes, and other market forces. In an effort to account for seasonal variations in patient census, our analysis compared data from the same financial quarters (calendar months).

Finally, PBT has also been incorporated as an accepted modality under National Comprehensive Cancer Network guidelines over the course of this study for several sites: thoracic (ie, mesothelioma, thymoma, esophageal, and non–small-cell lung cancer), GI tumors (ie, hepatobiliary cancers), CNS tumors (ie, chordoma, ependymoma, medulloblastoma, meningioma), mucosal melanomas, and various sarcomas and lymphomas³⁷; yet a significant proportion of these patients still required appeal, as outlined by our results. In addition, our center’s data from 2014 to 2016,¹⁰ along with other centers’ data from 2015 to 2018,⁹ indicate decreasing approval rates throughout the course of this study, supporting the validity of our findings.

In conclusion, this multifaceted strategic approach has optimized navigation through the PA and appeal process at our large academic PTC, improving access to PBT while alleviating administrative burden for patients and providers. The underlying concepts may be adapted for other oncologic practice settings facing analogous PA-related issues to promote timely treatment of patients with cancer.

Appendix

Fig A1.

Educational advantage of advanced practice dosimetrists (APDs). CMD, certified medical dosimetrist; RN, registered nurse; Mgmt, management.

Fig A2.

(A) Appeal letter. (B) Sagittal view of patient’s disease. As shown, the disease is abutting the superior-posterior aspect of the patient’s brainstem. (C). Proton therapy is the standard of care to treat the patient’s astrocytoma; letter continued. (D) [Insurance company]’s medical policy is outdated and not consistent with the current state of the evidence and national guidelines; letter continued.

AUTHOR CONTRIBUTIONS

Conception and design: Eric D. Brooks, Matthew S. Ning, Matthew B. Palmer, G. Brandon Gunn, Aashish K. Shah, Steven J. Frank

Administrative support: G. Brandon Gunn, Matthew B. Palmer, Aashish K. Shah, Steven J. Frank

Collection and assembly of data: Eric D. Brooks, Matthew S. Ning, Matthew B. Palmer, G. Brandon Gunn, Aashish K. Shah, Steven J. Frank

Data analysis and interpretation: Eric D. Brooks, Matthew S. Ning, Matthew B. Palmer, G. Brandon Gunn, Aashish K. Shah, Steven J. Frank

Manuscript writing: Eric D. Brooks, Matthew S. Ning, Matthew B. Palmer, G. Brandon Gunn, Aashish K. Shah

Final approval of manuscript: All authors

Accountable for all aspects of the work: All authors

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Strategic Operational Redesign for Successfully Navigating Prior Authorization Barriers at a Large-Volume Proton Therapy Center

The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated unless otherwise noted. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/op/authors/author-center.

Open Payments is a public database containing information reported by companies about payments made to US-licensed physicians (Open Payments).

Matthew B. Palmer

Patents, Royalties, Other Intellectual Property: Patent, Automatic Optimal IMRT/VMAT treatment planning system, a joint patent with Philips Medical Systems and The University of Texas System

Steven J. Frank

Leadership: C4 Imaging, National Comprehensive Cancer Network

Stock and Other Ownership Interests: C4 Imaging

Honoraria: Boston Scientific, Hitachi, Varian Medical Systems

Consulting or Advisory Role: Hitachi, Breakthrough Chronic Care, Varian Medical Systems

Research Funding: Elekta, Hitachi, Eli Lilly

Patents, Royalties, Other Intellectual Property: I have developed patents at the University of Texas MD Anderson Cancer Center. These patents have been licensed to C4 Imaging.

Travel, Accommodations, Expenses: National Comprehensive Cancer Network, Boston Scientific

Aashish K. Shah

Employment: Provision Healthcare

No other potential conflicts of interest were reported.