Dr. Alexandra Zaleta discusses how most most cancers sufferers face prior authorization delays, regardless of 95% being authorized, highlighting the necessity for reform.
Many people receiving remedy to deal with their most cancers confronted insurance coverage pink tape and administrative inefficiencies, leading to time toxicities, emotional and monetary pressure, in addition to inequities in entry to care, based on analysis entitled ‘The Insurance coverage Maze: How Most cancers Sufferers Get Misplaced within the Pink Tape of Utilization Administration’, which was revealed within the 2025 Pink Tape Report by CancerCare.
A set of insurance coverage practices known as, known as utilization administration, is used to regulate prices by managing when, how and whether or not sure remedies are authorized, and this examine underscores the necessity to reform these practices. Prior authorization and protection disruptions routinely intrude with affected person care, taking time away from remedy and directing it in the direction of the insurance coverage processes. In response to the analysis, has led to advocacy for a extra significant, and patient-centered, strategy.
This analysis was based mostly on a nationwide survey of 1,201 sufferers who had been handled for his or her most cancers, and examined the consequences of protection adjustments and prior authorizations on well timed entry to care, revealing the real-world penalties of utilization administration.
“For me, it is this contradiction: virtually everyone seems to be put by the method, and ultimately, their preliminary doctor-prescribed care is authorized. However within the meantime, they face vital care delays, time burdens, and impacts on their high quality of life,” Dr. Alexandra Zaleta, examine creator and principal investigator of the CARE Research, stated in an interview with CURE. “This impacts their stress ranges, their funds, and their belief within the healthcare system.”
To delve deeper into this matter, Zaleta sat down for an interview with CURE to focus on survey findings, in addition to explains what these delays in care point out concerning the present system.
Zaleta, strategic chief and scientist, is the affiliate vice chairman of Analysis and Insights at CancerCare the place she features as an in-house professional on understanding challenges confronted by folks affected by most cancers.
CURE: To start, out of your perspective, what was essentially the most placing or regarding statistic that emerged from the survey you lately performed and revealed?
Zaleta: For me, the contradiction lies in these findings: virtually everybody was put by prior authorization. This was a survey of people handled for most cancers within the yr earlier than taking the survey. Eighty-five p.c reported present process prior authorization in some unspecified time in the future, and 76% within the final yr alone. But, 95% of those prior authorizations have been in the end authorized. The vast majority of these authorizations are authorized, however solely after lots of people confronted diagnostic and remedy delays, and super burdens on their time and high quality of life.
Due to this fact, for me, the true ache level is that just about everyone seems to be put by this course of, and the vast majority of the time, after appeals and every little thing else, their care is ultimately authorized. Nonetheless, this approval comes solely after 29% skilled delayed diagnoses, 40% had their remedy delayed, and half needed to [personally] get entangled in combating the pink tape. Many of those people misplaced a number of days of their lives battling a single prior authorization incident. Quite a lot of these of us aren’t simply going by it as soon as; they’re going through prior authorization two, three, 4, and even 5 instances within the final yr alone. Every time, they probably must roll up their sleeves and spend a day or a number of days, with some even reporting they needed to spend an entire week or extra combating pink tape. This time may have been spent specializing in their restoration and therapeutic, which ought to be the highest precedence, or on their household and family members, or on different issues they care about like work, different roles, or social obligations.
For me, it is this contradiction: virtually everyone seems to be put by the method, and ultimately, their preliminary doctor-prescribed care is authorized. However within the meantime, they face vital care delays, time burdens, and impacts on their high quality of life. This impacts their stress ranges, their funds, and their belief within the healthcare system.
How would you describe prior authorization and associated insurance coverage boundaries to somebody who has simply acquired a most cancers prognosis?
At its easiest stage, everyone knows that healthcare within the U.S. is absolutely costly. So, at its easiest stage, it is a cost-control measure carried out by insurers and different gamers within the house. Its acknowledged aim is to examine that the remedy a health care provider prescribes is medically vital and applicable for the situation. That is the insurance coverage trade’s framing: to assist management prices and, theoretically, guarantee folks obtain applicable, high quality care.
Nonetheless, our present ache level is that the system is being utilized in a means that is widespread and inefficient, creating affected person hurt and probably not even producing value financial savings for folks with most cancers. So, whereas its supposed objective is to extend effectivity and assist management prices, what we frequently see in the true world is the other for folks residing with most cancers: they face inefficiencies, delays, and probably even elevated prices by the point all the course of is full.
What does this point out concerning the present system? Do you view this as proof of pointless delays quite than efficient value oversight — and the way do you interpret that determine?
From our perspective, it is an issue. Whereas we perceive the supposed objective of one thing like prior authorization, when 85% of people are put by this course of — three-quarters within the final yr alone — and 90% of these are authorized out the gate, it nonetheless takes many individuals days and even weeks to get that first reply. The remaining people then must battle for approval, extending the wait to achieve that 95% approval price by much more days, weeks, and in some instances, months, all to in the end have their doctor-prescribed care authorized.
To us, it simply does not make sense; there’s clearly a severe inefficiency on this system the place the default is to place folks by the prior authorization course of, solely to reach at that willpower. The method itself is probably not very clear or clear, so persons are left attempting to determine the right way to navigate it. They is likely to be calling their physician’s workplace for understanding, whereas the physician is concurrently working behind the scenes and likewise attempting to help the affected person and their family members by answering questions and easing anxieties. This can be a genuinely scary and worrying course of, particularly since many individuals are caught off guard. Whereas some are conscious this would possibly occur, both as a result of it has earlier than or their physician knowledgeable them, many will not be. And that, I imagine, is a major ache level. It catches folks off guard.
Once more, from our perspective, if 95% of those instances within the most cancers context are being authorized, however solely after inflicting care delays, time burdens, and a worse high quality of life, that, to me, is a system that wants reform. It merely does not make sense that that is the default expertise for folks residing with most cancers.
Reference:
“The Well being Insurance coverage Maze: How Most cancers Sufferers Get Misplaced within the Pink Tape of Utilization Administration” by CancerCare. 2025 Pink Tape Report by CancerCare.
For extra information on most cancers updates, analysis and schooling, don’t overlook to subscribe to CURE®’s newsletters right here.