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Addressing the Backlog of Cancer Patients

Can Prior Authorization Help Improve the Backlog of Cancer Patients Created by the Pandemic?

Canadians with cancer have been experiencing longer times to diagnosis and medical treatment during the pandemic. A backlog has been building that will take years to address, according to Dr Tony Eskander, surgical oncologist of the mouth, throat and neck at Sunnybrook Health Sciences Centre in Toronto, during  Dr. Brian Goldman’s June 2021 White Coat Black Art podcast – Delayed Diagnosis

“There are many stories of patients who’ve tried to get medical attention, but it was virtual and therefore couldn’t have a full physical examination, and sometimes that has delayed their diagnosis. Patients have been coming in with larger tumors or undiagnosed tumors.”

According to the Canadian Cancer Society’s website, because of COVID-19 there have been delays in common screening tests including mammograms, stool tests for detecting colorectal cancer and Pap tests for detecting cervical cancer. A July 2020 survey conducted by the Society also found almost half of patients reported having cancer care appointments cancelled or postponed during the pandemic. According to the Society’s website the Canadian Institute for Health Information, found a 20% reduction in cancer surgeries between April and September 2020 versus the same period in 2019.

Misdiagnosis is also a concern. According to one patient interviewed for Dr. Goldman’s podcast, her stomach pain, initially diagnosed as irritable bowel syndrome (IBS), was later diagnosed as stage 2 ovarian cancer. She believes that if she had been able to visit her physician in person, her cancer could have been diagnosed earlier. 

“With delays in diagnosis and treatment, we know that patients have poor curability and poor survival outcomes for management of their cancers… [a recent study] actually demonstrated exactly how much a 2-or 4-week delay for any given cancer would lead to worse survival outcomes,” said Dr Eskander.

For his part, Dr. Mark Vincent, Medical Oncologist at the London Regional Cancer Program, who sees patients with lung and gastrointestinal cancers, told listeners of one of our podcasts – Prior Authorization and Oncology  –earlier this year that without the pandemic there are still delays in treatments due to a “complicated bureaucratic [prior authorization] process [by insurance companies] that seems to be obstipated”. Although coverage decisions sometimes go smoothly Dr. Vincent’s experience is that “the worst situation is ‘maybe, but not yet’, and you have to argue back and forth”. When in this limbo “the patient is deteriorating in front of your eyes to the point where they become untreatable”.

According to Dr. Vincent “anything that makes the [prior authorization claims] process more efficient, less consumptive of doctor’s time, and gets rid of redundancies” would be helpful to stakeholders. Vincent believes that “doctors should not be doing a lot of this paperwork, it should be automatic. A small investment to fix this problem [compared to the dollar value of the new drugs that we put through our cancer centre every month] and have a software program that can facilitate this will have huge returns to the patients, doctors, the pharma industry, and even to private payers.”

This is where the Simplify Prior Authorization (SPA) initiative can help. Connex Health and the Pangea Group were engaged in early 2000 to examine the challenges and opportunities in prior authorization in employee benefits. Following the release of the white paper in fall 2000, the SPA initiative was launched with a mandate to explore opportunities to improve the patient experience based on several objectives:

  1. Advocate for improvements in the prior authorization (PA) claims process to improve the plan member experience and reduce the time and administrative burden when plan members are prescribed a drug which requires PA
  2. Examine the potential role of a resource for PA stakeholders to improve knowledge and understanding of the PA claims process to improve the PA process
  3. Explore the potential to introduce an agnostic electronic prior authorization (ePA) platform for PA stakeholders that would create a more efficient process and ease the administrative burden on PA stakeholders, including payers, without impinging on their proprietary criteria.

The pandemic has highlighted the importance of improving the way care is delivered to maximize limited resources, including screening and treatment. While SPA and an ePA platform will not on their own solve the significant backlog of undiagnosed and under-treated cancer patients created by the pandemic, they are working to deliver solutions that will create administrative efficiencies to free up valuable time for PA stakeholders, reducing the time oncologists, drug access navigators and patient support programs spend on navigating the complex, and largely manual PA process. For practitioners, this means they have more time to be face to face with patients, delivering diagnosis and treatment rather than administrative functions and advocating for treatment.

Introducing a more integrated claims process between stakeholders could make a big difference to patients, but stakeholders are often reluctant to collaborate because of the time and resources it can take to make changes or because of competitive pressures. If the pandemic has proved one thing, it is that we must all work together to deliver better care for patients.

In fall 2021 the SPA initiative is moving forward into its next phase. An ePA pilot will deliver an integrated experience for stakeholders, and a not-for-profit online resource will create a forum to provide additional insights to PA stakeholders on the PA process. All stakeholders are invited to the table.

We can and we must do better. When we do, we all benefit.

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