Findings from a first-of-its-kind national survey are included in “The Health Insurance Maze: How Cancer Patients Get Lost in the Red Tape of Utilization Management,” a new report from CancerCare which details the impact that prior authorization requirement and coverage stoppages have on patients with cancer.
Eight-five percent of patients surveyed required prior authorizations for their insurance companies before they could receive a prescribed cancer treatment, which led to significant delays and stress for these patients. Rates were highest among patients with employer-sponsored insurance plans.
"Our findings make clear that utilization management policies—while intended to manage costs—often create dangerous delays and stress for people fighting cancer. And in most cases, people who get insurance from their employer faced the greatest barriers," stated principal investigator Alexandra Zaleta, PhD, Associate Vice President of Research and Insights at CancerCare. "Policymakers and insurers must streamline these processes so patients can focus on treatment, not red tape."
About the Survey
The investigators conducted a national survey of administrative barriers to cancer diagnoses and treatment. A total of 1,201 adult patients with cancer who received treatment within the past year participated in the survey. Participants completed the survey between September and December 2024.
A sample size of 47,225 potential national participants were screened for eligibility critera: age of at least 26 years, treated for cancer within the past year, and insurance eligibility criteria.
A total of 569 participants had employer insurance plans, 408 had Medicare Advantage, and 224 had traditional Medicare plans.
A majority of survey respondents were women (58%), unmarried (52%), non-Hispanic White (73%), full-time workers (40%), had a Bachelor’s degree or higher (45%), and lived in the South (41%). The most common cancer diagnosis was breast cancer (30%) followed by prostate cancer (12%) and blood cancer (12%). The most common treatment type within the past 12 months was radiation therapy for 51%, followed by immunotherapy in 48% and intravenous chemotherapy in 45%. Patients had a median of 2 years since their cancer diagnosis.
Key Findings
Among the participants, 14% reported treatment coverage stoppages within the past year and 18% at some point in their care journey. Among patients who reported a treatment interruption due to coverage, 27% said that it lasted from 3 weeks to more than a month. For those who switched treatments due to a coverage stoppage, 45% said that it led to worse adverse effects and 38% said that it resulted in more expensive treatment.
Treatment delays were reported by most patients due to navigating utilization management hurdles; 95% of these patients reported that their treatment was ultimately approved, but 29% experienced a delay in diagnosis and 40% experienced a delay in treatment.
For 51% of patients, the time spent on a single prior authorization amounted to one lost business day, 2 to 3 business days for 27%, and a full business week or more for 12%.
Employer plans were associated with the most red tape, followed by Medicare Advantage insurance and then traditional Medicare.
Prior authorization demands were not limited to a single type of treatment. Forty-three percent of survey respondents reported undergoing prior authorization through their employer insurance plans for at least five types of cancer treatments (ie, surgery, radiation, chemotherapy, imaging, etc.) compared with 23% with Medicare Advantage and 15% with traditional Medicare.
Approximately one-third of participants said that these insurance utilization management issues had an impact on their emotional and social well-being, financial well-being, physical well-being, and/or trust in the health-care system.
“For people with cancer, delays and denials caused by utilization management can mean the difference between life and death,” said Christine Verini, Chief Executive Officer of CancerCare. “Our research exposes how these practices impact patients, because behind every policy is a person fighting for their life. The results in this report shed light on the true costs of utilization management—and are critical to challenging systems that stand in the way of timely, lifesaving care.”
Disclosure: For full disclosures of the study authors, visit cancercare.org.
