I breathed a sigh of relief. It was Friday afternoon of the second week of my oncology fellowship, and for the first time, I had submitted chemotherapy orders on my own without an error message popping up. I forwarded the orders to the attending physician for a required verification and second signature, and then walked into Clinic Room 6 to see Mrs R, a lovely woman who had recently received a diagnosis of hepatocellular carcinoma. We had met a few days prior and discussed her diagnosis and treatment options. We agreed on a treatment plan and to start chemotherapy the following week, while she took care of a few pending projects. She looked to be in good shape today, and we spoke for a solid 25 minutes about what to expect with chemotherapy, adverse effects to watch for, the emergency hotline phone number, and so on. After that, we said goodbye, and I went to see my next patient. Soon the attending physician got back to me and confirmed that the chemotherapy orders looked good, and she had signed them.

While wrapping up for the day, I received an email from the social worker alerting me that Mrs R’s chemotherapy might be placed on hold because approval from her insurance was still pending. I will not bore you with the details, but suffice it to sa more than 10 telephone calls were made and 20 emails exchanged over the next 30 minutes to sort out this issue, which was not resolved by the end of the day. A ton of paperwork, telephone calls, and emails followed the next Monday, and we had to delay starting Mrs R’s chemotherapy. Several team members, including nurses, social workers, financial counselors, administrators, and pharmacists, eventually worked things out, and Mrs R was able to receive her chemotherapy. The overall delay was a week.

This episode caused significant distress for Mrs R an me. Fortunately, it likely will not significantly affect he long-term outcome. This event has a good ending, at least in the short term, in that Mrs R ultimately started chemotherapy, has been tolerating it relatively well, and is getting close to the time to assess her tumor response. It was an important early lesson for me, though, in understanding that oncology is not immune to—and perhaps even more prone to&mdash;issues with getting clearance from insurance companies. It is important for oncology trainees to realize that obtaining prior authorizations is part of the oncologist’s job and be mentally prepared to deal with them. Prior authorization is a requirement instituted by insurance companies with the apparent goal of curbing healthcare costs in the setting of rising expenditures and complexity of care. It may extend into several facets of cancer care, including diagnostics (molecular testing, radiology) and therapeutics (oral and intravenous drugs, supportive medications). It is not as though prior authoriziations represent new experiences for oncology fellows. Most internal medicine residents spend hours in residency trying to obtain approval for a direct oral anticoagulant for a patient or arrange a new wheelchair for an octogenarian whose current one is on its last wheels. However, the stakes&mdash;financially and urgency-wise&mdash;are often much higher in oncology.

To confirm that this was not a one-off case and isomething oncologists deal with often, I observed and spoke with several of our faculty members. Just a couple of days in the oncology clinic were enough to convince me that this is a rampant issue. I saw attending physician after attending physician spend precious minutes on the phone with insurance companies to get tests or therapies cleared for their patients. One particular instance stands out—when an attending physician spent 45 minutes, mostly on hold, trying to get an octreotide scan cleared for a patient with a neuroendocrine tumor. The physicians’ poise, persistence, and passion to provide the best care for their patients really stood out.

I also spoke with colleagues and faculty members across institutions, and they confirmed that this is a dailystruggle and, perhaps, their least favorite part about being an oncologist. A quick literature search brought me to an article recently published in the Journal of Oncology Practice. Kirkwood et al studied the results of The American Society of Clinical Oncology’s Medicare Physician Compare survey data in 2017, which found that almost two-thirds of oncologists reported payer strains as the primary pressure in their job.

 Prior authorization procedures were the main source of stress.

Several prominent hematologists and oncologists have voiced their individual experiences on Twitter. Some examples from just 1 day (August 15, 2018):

Navneet Majhail, MD (@BldCancerDoc), 10:49 am: 

“Dear insurance company, my patient has been on tacrolimus for 6 months post-transplant, pls don’t ask me for prior auth when I send prescription with new dose of the same drug.”

Emil Lou, MD, PhD (@cancerassassin1), 11:03 am: 

“Yesterday I had to call an insurance company for peer-to-peer review questioning my orders for a spine MRI…to rule out cord compression.’’

“Dear insurance company, my patient has severe hemophilia A and is on prophylaxis factor 8, with no dose change for past 10 years. Why do you need a prior auth every 3 months?’’

As prickling as the issue can be, I do not think this is an “us versus them” debate. I do not believe insurance companies—or their representatives&mdash;are out there trying to deny the right care for patients. The system simply is flawed and is not going to be fixed within day. To provide the best care for the patients in front of us, oncologists must once again go above and beyond as needed. It behooves us to educate ourselves and work together with available local resources to get the best care for our patients. Most cancer centers now have large multidisciplinary teams handling prior authorization requests, especially for drugs. For example, our cancer center has site-specific oral chemotherapy teams that process requests for chemotherapy efficiently a with expertise. Different cancer centers have differe systems and levels of help. Asking colleagues and attendings for help, planning ahead for diagnostic and treatment decisions, and working with the local multidisciplinary team comprising nurses, social workers, and pharmacists are ways a trainee oncologist can deal with this initiation to prior authorizations.

A few weeks after the episode related to Mrs R, I was looking through the records of patients I would see in clinic the next day. I noticed a patient had progressed through second-line therapy for metastatic colon cancer. Before doing anything else to prepare for the patient visit, I composed an email to our gastrointestinal pharmacy team about possibly needing regorafenib. They were able to start treatment without delay.

Kirkwood MK, Hanley A, Bruinooge SS, et al. The state of oncology practice in America, 2018: results of the ASCO Practice Census survey. 

. 2018;14(7):e412-e420. doi: 10.1200/JOP.18.00149.

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To provide the best care for the patients in front of us, oncologists must once again go above and beyond as needed.

Arjun Gupta, MD

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The Patient Is Ready, But the Insurance Is Not