UCLA CENTER FOR
HEALTH POLICY RESEARCH .

 

 

Health Policy Fact Sheet

April 2021

 

Insurance Requirements Create
Barriers to Timely Care

AJ Scheitler, Susan H. Babey, Riti Shimkhada, Beth Glenn, and Ninez A. Ponce

 

SUMMARY

© Getting approvals, or prior authorizations,
for treatment from insurance companies
was cited as a significant stressor both by
patients with metastatic breast cancer (MBC)
and by the health care providers who treat
them.

® Both patients and providers expressed
frustration over the time and energy needed
to arrange for necessary prior authorizations
and advocate for coverage.

© Specifically, advocates for patients with MBC
feel prior authorization and step therapy
processes should be improved.

In 2019, 30,650 individuals were diagnosed with
breast cancer in California, and 4,620 died from

the disease.' Metastatic breast cancer, also
called stage 4 or advanced breast cancer,
was the cause of nearly all of these deaths.
An estimated 30% of women diagnosed
with early-stage breast cancer will go on to
develop MBC. The five-year survival rate

for MBC is only 27%, compared to 91%

for breast cancer that has spread to lymph
nodes and 99% for cancer that is confined to
the breast."

In this fact sheet, we present findings from
interviews, discussions, and studies (see
boxed section) on insurance-related barriers,
and we recommend policy solutions that
could improve access to care for patients
with MBC.

 

he literature review suggested that

MBC patients experience many
insurance-related barriers. Views expressed
during interviews echoed the findings from
our literature review, suggesting that MBC
patients often struggle with insurance-
related frustrations. Numerous respondents
referenced the following:

Time and effort needed to secure coverage
for prescribed treatment. Patients

overwhelmingly expressed frustration with
the insurance system, particularly the need

for pre-authorizations and the time to
appeal some decisions. One patient said:

It makes it very difficult to fight for your
life and be well. I trust that if a drug
has been approved for Stage 4 cancer and
an oncologist wants to use it on me, we
should just get it, but that's not how our
world works,

Prior authorizations emerged as a major
barrier in timely access to treatment in the
literature, as well as in responses from our

 

 
 

 

Twitter chat and interviews.?4 Not only do
prior authorizations and subsequent appeals
cause delays, but the process is both time-
consuming and anxiety inducing. Patients
recommend to others that they take a strong
self-advocacy position and stay on top of
providers to move schedules along, and that
they be prepared to fight with insurance
companies over authorizations and payments.
Patient respondents noted that the time

and energy required to dispute insurance
companies' authorization decisions would be
better spent focusing on their fight against
the disease.

Too many "steps" to follow. Patients are
frustrated when they are subjected to step
therapy, which requires treatment A to fail
before treatment B can be pursued, even if
the physician believes strongly that treatment
B is preferable.

Fear that changing plans will reduce
coverage. Several patients and providers
specifically mentioned the importance of
having insurance plans continue to cover
pre-existing conditions. Without this
assurance of coverage regardless of pre-
existing conditions, as mandated by the
Affordable Care Act, many other barriers are
exacerbated, especially cost-related barriers.
This fear is particularly strong among women
who may need to leave their jobs during the
course of treatment, potentially experiencing
a change in insurance coverage.

UCLA CENTER FOR HEALTH POLICY RESEARCH

Recommendations

Our legislative scan documented areas
where California has made progress
and identified areas of need based on
our study findings. Recent legislative
efforts to improve treatment choices
for patients, such as SB 1452 (proposed
in 2020 but not passed), have involved
easing or removing prior authorizations
of step therapy review for medications.
Policymakers could consider:

¢ Improving prior authorization and step
therapy processes for quicker turnaround
time.

¢ Eliminating prior authorization
requirements and step therapy for
metastatic cancers, given the special need
for timely treatment.

Author Information

AJ Scheitler, EdD, is the director of stakeholder
relations at the UCLA Center for Health Policy
Research (UCLA CHPR). Susan H. Babey, PhD,
is a senior research scientist and co-director of
the Chronic Disease Program at UCLA CHPR.
Riti Shimkhada, MPH, PhD, is a public
administration analyst at UCLA CHPR. Beth
Glenn, PhD, is a professor in the Department of
Health Policy and Management at the UCLA
Fielding School of Public Health. Ninez A.
Ponce, MPP, PhD, is a professor at the UCLA
Fielding School of Public Health and director of
the UCLA CHPR.

Suggested Citation

Scheitler A, Babey SH, Shimkhada R, Glenn B,
Ponce NA. 2021. Insurance Requirements Create
Barriers to Timely Care. Los Angeles, CA: UCLA
Center for Health Policy Research.

 

 
 

1

 

American Cancer Society. 2020. Cancer Facts & Figures
2020. Atlanta, Ga.: American Cancer Society.

Agarwal A, Freedman RA, Goicuria F, et al. 2017. Prior
Authorization for Medications in a Breast Oncology
Practice: Navigation of a Complex Process. Journal of
Oncology Practice 13(A): €273-e282.

Lin NU, Bichkoff H, Hassett MJ. 2018. Increasing
Burden of Prior Authorizations in the Delivery of
Oncology Care in the United States. Journal of Oncology
Practice 14(9): 525-528.

Wallace ZS, Harkness T, Fu X, Stone JH, Choi HK,
'Walensky RP. Treatment Delays Associated With Prior
Authorization for Infusible Medications: A Cohort Study.

Arthritis Care & Research (Hoboken). September 10, 2019.

3 UCLA CENTER FOR HEALTH POLICY RESEARCH

Endnotes

Addressing Barriers to
Metastatic Breast Cancer
Care in California: Levers
for Policy Change

Metastatic breast cancer occurs
all across the United States,

but differences in health care
systems, health insurance
products, and population
characteristics create state-level
differences in the experiences of
patients. While there are national
standards and laws governing
different aspects of care for MBC
patients, state-level policies still
have significant impact.

The findings contained in this
fact sheet are drawn from a study
by the UCLA Center for Health
Policy Research and the UCLA
Center for Cancer Prevention and
Control Research on the barriers
to metastatic breast cancer

care in California. The study
report synthesized information
collected by listening to patients
and to both clinical and non-
clinical caregivers, as well as by
accessing published research, the
grey literature, and Twitter chat.

Read the full report:
httos://healthpolicy.ucla.edu/
publications/search/pages/
detail.aspx?PubID=2101

 

Read this publication
online

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