Sandra Hoyek, MD
Massachusetts Eye and Ear Infirmary
Dr. Sabin Dang, MD, addressed the repercussions of insurance prior authorization (PA) for intravitreal anti-VEGF within the field of retina. He and his colleagues carried out a retrospective analysis of PA requests spanning six months, from July 1, 2022, to December 31, 2022, utilizing the online SamaCare PA tool (www.samacare.com). The findings revealed that out of 33,178 PA requests, 97.6% received approval. The PA process resulted in care delays (defined as ≥30 minutes before obtaining authorization) for 93.6% of patients. The average time to authorization was 2.7 days, skewed by some patients waiting for days to even weeks to secure their PA requests. The median time for authorization was 9.6 hours, equivalent to over one business day.
Delving into the economic impact, an economic model demonstrated the burden of additional clinic visits, quantifying caregiver time for missing work, potential patient work hours lost, and commute time. This analysis estimated $116 in economic productivity loss for each extra visit to a retina clinic. Considering the 31,054 patients requiring additional visits due to delayed PA in this dataset, the cumulative economic loss due to missed work from these extra visits amounted to a substantial $3,633,232.83 over the study period.
These findings underscore the challenging and cumbersome nature of the PA process which leads to delayed care for the vast majority of patients. Not only does this place a substantial burden on patients, medical practices, and caregivers, but it also translates into a significant economic loss in productivity. Even more, a follow-on discussion underscored another critical issue: the fact that PA does not guarantee payment, potentially resulting in significant financial losses.
Based on his findings, Dr. Dang called for the pressing need to reevaluate and reform the PA process.
