TY - JOUR
T1 - Anti-VEGF Pharmaceutical Prior Authorization in Retina Practices
AU - Dang, Sabin
AU - Parke, D. Wilkin
AU - Sodhi, Guneet S.
AU - Eichenbaum, David
AU - Nielsen, Jared
AU - Danzig, Carl
AU - Lalwani, Geeta
AU - Moinfar, Nader
AU - London, Nikolas
AU - Kimura, Alan
AU - Jumper, J. Michael
AU - Lord, Ken
AU - Sheth, Veeral
AU - Pieramici, Dante
AU - Orlin, Anton
AU - Madson, Allison
AU - Horton, Monica
AU - Blim, Jill
AU - Cao, Jessica A.
AU - Thompson, John
AU - Khanna, Saira
AU - Wykoff, Charles C.
AU - Shah, Ankoor R.
N1 - Publisher Copyright:
© 2024 American Medical Association. All rights reserved.
PY - 2024/8/15
Y1 - 2024/8/15
N2 - IMPORTANCE Anti–vascular endothelial growth factor (VEGF) intravitreal injections, a mainstay of treatment for many retinal diseases to optimize visual outcomes, have been included in prior authorization (PA) initiatives. However, if clinicians are extremely accurate in their use of anti-VEGF medications, such administrative burdens may need reconsideration. OBJECTIVE To quantify PA for anti-VEGF medications (aflibercept, ranibizumab, and bevacizumab) that were approved and determine associated administrative burdens experienced by retina practices. DESIGN, SETTING, AND PARTICIPANTS Prospective multicenter quality improvement study conducted from January 2022 through June 2022, and participants were 9 private retina practices across the US. MAIN OUTCOMES AND MEASURES Overall rate of approval of PA requests, reasons for requesting PA, and overall rate of delay of care resulting from PA procedures. RESULTS In total, 2365 PA requests were recorded, 2225 of which met inclusion criteria. Overall, 2140 (96.2%) requests were approved. The most common reason for requesting PA, at 64% (1423 of 2225 requests), was reauthorization for a previously utilized medication. Of the 2140 approvals, 59.6% (1277) resulted in a delay in care greater than 24 hours, and 40% (863) were given on the date of service. In a granular analysis of a subset of delayed approvals, 23.9% (173 of 725) were approved within 1 day, 15.9% (115 of 725) were approved within 2 to 3 days, 21.5% (156 of 725) were approved within 4 to 7 days, 26.3% (191 of 725) were approved within 8 to 31 days, and 12.4% (90 of 725) were approved within more than 31 days. Overall, PA denial for step therapy was 2.9% (65 of 2225) of requests and uncovered diagnoses was 0.9% (20 of 2225) of requests. The median staff time spent to obtain a single PA was 100 (range, 0-200) minutes. CONCLUSIONS AND RELEVANCE In this study, PA requests were almost always approved but led to a delay in patient care in most patients. The current study suggests that the PA process may not be effective for retina specialists if these results can be generalized to other practices in the US and if less burdensome and less costly approaches could result in similar approval rates. Potential short-term solutions may include eliminating the PA process for bevacizumab and reauthorizations for established patients.
AB - IMPORTANCE Anti–vascular endothelial growth factor (VEGF) intravitreal injections, a mainstay of treatment for many retinal diseases to optimize visual outcomes, have been included in prior authorization (PA) initiatives. However, if clinicians are extremely accurate in their use of anti-VEGF medications, such administrative burdens may need reconsideration. OBJECTIVE To quantify PA for anti-VEGF medications (aflibercept, ranibizumab, and bevacizumab) that were approved and determine associated administrative burdens experienced by retina practices. DESIGN, SETTING, AND PARTICIPANTS Prospective multicenter quality improvement study conducted from January 2022 through June 2022, and participants were 9 private retina practices across the US. MAIN OUTCOMES AND MEASURES Overall rate of approval of PA requests, reasons for requesting PA, and overall rate of delay of care resulting from PA procedures. RESULTS In total, 2365 PA requests were recorded, 2225 of which met inclusion criteria. Overall, 2140 (96.2%) requests were approved. The most common reason for requesting PA, at 64% (1423 of 2225 requests), was reauthorization for a previously utilized medication. Of the 2140 approvals, 59.6% (1277) resulted in a delay in care greater than 24 hours, and 40% (863) were given on the date of service. In a granular analysis of a subset of delayed approvals, 23.9% (173 of 725) were approved within 1 day, 15.9% (115 of 725) were approved within 2 to 3 days, 21.5% (156 of 725) were approved within 4 to 7 days, 26.3% (191 of 725) were approved within 8 to 31 days, and 12.4% (90 of 725) were approved within more than 31 days. Overall, PA denial for step therapy was 2.9% (65 of 2225) of requests and uncovered diagnoses was 0.9% (20 of 2225) of requests. The median staff time spent to obtain a single PA was 100 (range, 0-200) minutes. CONCLUSIONS AND RELEVANCE In this study, PA requests were almost always approved but led to a delay in patient care in most patients. The current study suggests that the PA process may not be effective for retina specialists if these results can be generalized to other practices in the US and if less burdensome and less costly approaches could result in similar approval rates. Potential short-term solutions may include eliminating the PA process for bevacizumab and reauthorizations for established patients.
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U2 - 10.1001/jamaophthalmol.2024.2217
DO - 10.1001/jamaophthalmol.2024.2217
M3 - Article
C2 - 38935350
AN - SCOPUS:85200919415
SN - 2168-6165
VL - 142
SP - 716
EP - 721
JO - JAMA Ophthalmology
JF - JAMA Ophthalmology
IS - 8
ER -