1110 - Assessing Insurer Market Share Association with Insurance Denials, Appeals, and Prolonged Prior Authorization for Patients Undergoing Proton Beam Therapy

12:40pm - 12:45pm ET

Room 259

Presenter(s)

Allison Randolph, MD, MBA - Johns Hopkins Medicine, Baltimore, MD

A. Randolph V¹, J. Jackson², N. Anabaraonye³, G. Yenokyan⁴, and C. Deville Jr⁵; ¹Johns Hopkins Radiation Oncology, Baltimore, MD, ²Johns Hopkins Sibley Memorial Hospital, Washington DC, DC, ³Dana-Farber Brigham Cancer Center, Boston, MA, ⁴Johns Hopkins Biostatistics Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, ⁵Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD

Purpose/Objective(s):

Differences in overall insurance approvals of Proton Beam Therapy (PBT) have been studied in patient-based contexts (e.g., by disease site); however, insurer-based contexts have been less reported. To further understand the impact of the PBT prior authorization (PA) administration burden, our specific aim was to evaluate denial, appeal, and prolonged PA proportions for PBT and to assess for associations with insurer market share.

Materials/Methods:

We performed a retrospective, observational cohort analysis. Data was collected from a single site, academic institution. This study included patients who were referred for and elected PBT between Oct 2019 - July 2022. Of 1084 initially considered patients, 1008 were submitted for insurance clearance and 76 patients were excluded from analysis due to direct pay or charity care. Thereafter, 471 patients were excluded for market share analysis due to public insurance (Medicare, Medicaid or veterans), leaving 531 patients included in the market share analysis. Variables included age (>65 and <=65), sex (male and female), disease site (CNS, gynecologic, soft tissue sarcoma, breast, head/neck, thoracic, gastrointestinal, lymphoma, prostate, and pediatrics), specific insurer, and insurer market share (<6M members, 6-24M members, >24M members). Outcome metrics were insurance denial, appeal, and prolonged PA. Prolonged PA was defined as PA duration longer than 7 days. Associations between categorical variables and outcomes were assessed with chi squared. Univariate multiple logistic regression analysis was used to assess predictors for outcome metrics, reported in odds ratios. Statistical analysis utilized R (R Core Team, version 4.4.2).

Results:

Proportions of denials and prolonged PAs across cohorts were 8.8% (89/1008) and 44.9% (453/1008) respectively for submitted patients. The proportion of appeals was 3.9% (36/919). Denial and prolonged PA proportions for privately insured patients were 13.4% (71/531) and 58% (308/531) respectively for submitted patients. The proportion of appeals for privately insured patients was 6% (28/460). Insurance denials were significantly higher among insurers with 6M-25M beneficiaries (aOR: 4.91; CI: 2.15-11.19; p<0.01) and insurers with greater than 25M beneficiaries (aOR: 6.31; CI: 3.23-12.32; p<0.01). Insurance appeals were significantly higher among insurers with 6M-25M beneficiaries (aOR: 5.85; CI: 1.67-20.54; p<0.01) and insurers with greater than 25M beneficiaries (aOR: 7.76; CI: 2.71-22.22; p<0.01). Prolonged PA were significantly higher among insurers with greater than 25M beneficiaries (aOR: 1.56; CI: 1.04-2.33; p=0.03).

Conclusion:

Insurance denials, appeals, and prolonged PA were associated with insurers with larger numbers of beneficiaries in dose-dependent fashion, impacting PBT utilization and time to treatment initiation. These findings may be utilized to help to inform solutions and care gaps related to insurer characteristics.