A new nationwide survey of more than 750 radiation oncologists confirms that prior authorization harms people with cancer by causing treatment delays, abandoned treatments, hospitalizations and patient deaths.

Findings (view executive summary) also make clear that the problem of prior authorization is growing worse, with patients now experiencing longer radiation therapy treatment delays than during the height of the COVID-19 pandemic. Results of the survey, the latest in a series from the American Society for Radiation Oncology (ASTRO), reinforce the urgent need for Congress to pass prior authorization reform legislation and prevent further harm to people with cancer.

Nearly a third (30%) of the radiation oncologists — doctors who provide radiation therapy and care for more than one million Americans each year — said in the survey that prior authorization has caused emergency room visits, hospitalization or permanent disability for their patients, and 7% said it has led or contributed to a patient’s death. Respondents also detailed other ways prior authorization undermines cancer outcomes:

  • Widespread delays: Nearly all radiation oncologists (92%) said that prior authorization causes treatment delays for their patients. Delays occur for more than a third of their patients (35%), on average.

  • Longer delays: More than two-thirds of doctors (68%) said the average prior authorization delay for their patients lasts five days or more, up from half (52%) reporting similarly long delays in ASTRO’s 2020 survey. Delays in the start of radiation therapy are associated with an increased risk of cancer progression, complications and death.

  • Abandoned treatment: One-third of the doctors (33%) said prior authorization has led to their patients abandoning radiation treatment, with an average of 1 in 10 patients leaving treatment. More than 8 in 10 physicians (82%) said prior authorization has forced them to resort to a less optimal treatment, and that this happens with greater frequency than in previous ASTRO surveys.

  • Medication barriers: Many radiation oncologists reported difficulty obtaining insurance approval for medicines needed for the effects of cancer treatment, including medications for nausea (23% of respondents), erectile dysfunction aids (18%), prescription skincare (17%) and pain medicine (opiate 40%, non-opiate pain 10%).

Radiation oncologists overwhelmingly said the problem of prior authorization has grown worse, with more than 8 in 10 (85%) reporting that their burden increased in the past three years. Nearly all (94%) said prior authorization worsens staff burnout in their cancer clinics. Respondents also detailed other ways it adds to the strain on cancer providers and clinics:

  • Staffing needs: Four in 5 physicians said prior authorization made it necessary to reallocate staff time to manage the prior authorization process at their clinic, and 3 in 5 said they had to hire additional staff.

  • Heavier Burden: A majority of survey respondents (54%) said more than half of their cases require prior authorization approval, up from 51% in 2020 and 44% in 2019. Radiation oncologists in 2024 estimate that 71% of their requests are initially approved. For those that are denied, ultimately 73% of the denials are overturned on appeal. Rates of initial approvals and overturned denials are both up from previous ASTRO surveys.

  • Peer review flaws: Just two-thirds (66%) of peer-to-peer consultations for radiation therapy treatments are performed by radiation oncologists. Key issues with the process include insurance companies’ lack of transparency on the requirements for approval, peer reviewers not being able to make decisions and scheduling inflexibility that adds to patient delays.

“These survey findings confirm what radiation oncologists witness daily: prior authorization policies are failing people with cancer, causing avoidable delays that are dangerous and, in too many cases, deadly,” said Howard M. Sandler, MD, FASTRO, Chair of the ASTRO Board of Directors.

Radiation oncologists face the greatest likelihood of any clinical specialty to encounter prior authorization, and ASTRO members consistently rank prior authorization as the top problem facing their practices in yearly benchmarking surveys. ASTRO supports multiple policy solutions to address this flawed system, including legislation currently circulating in both chambers of Congress.

“The ASTRO-supported Improving Seniors’ Timely Access to Care Act of 2024 (S.4532, H.R.8702) would bring much-needed reform to prior authorization for Medicare Advantage plans, such as establishing a real-time process for coverage decisions,” said Dr. Sandler. “We encourage Congress to act now to help end these life-threatening delays and put Medicare Advantage on a path toward transparency and accountability by passing this legislation before the current session ends.” The bill currently has 228 House and 58 Senate co-sponsors.

Additional results and information about the survey, which was conducted online in September and October 2024 (N=754, 16% response rate), are available in the executive summary.

This news release was published by the American Society for Radiation Oncology on December 4, 2024.