Denial for survivorship care, particularly supportive care services, is frequent. While denial is common, it appears providers and programs often have a process to work through denials and prior authorization processes, regardless of payer type or region of the country. The difficulties posed by insurance policies with denials/deferrals inhibit the delivery of guideline concordant care; these challenges impose potential harm to patients, increase cost to the health care system, and impose undue burden and stress on clinicians and administrators. There is a need to change the policies and practices that regulate re-imbursement for guideline concordant imaging studies and supportive care services for cancer survivors.
For over fifteen years since the Institute of Medicine released “Lost in Transition,1” it has been clear that cancer survivors have a unique trajectory after the completion of their cancer treatment. Based on genetics, age at receipt of cancer treatment, treatment exposures, and lifestyle, cancer survivors are at increased risk of cancer recurrence, secondary cancers, chronic health conditions, and impairments in quality of life as a consequence of aging, underlying risk factors, and prior cancer treatment.5 Providing risk stratified guideline concordant care has been shown to improve the morbidity and mortality associated with secondary cancers in cancer survivors.6–8 Similarly, improving access to supportive care services (i.e., cardiooncology, cancer rehabilitation, psychooncology) has been demonstrated to help patients recover from the effects of their cancer and treatment related impairments.9,10 Improving access to evidence-based survivorship care provides an opportunity to reduce the morbidity and mortality associated with a cancer diagnosis while also providing a platform for quality survivorship care.10
Despite the development of guidelines and the potential for improved outcomes in cancer survivors in terms of reducing cancer recurrence and chronic diseases, adherence to guideline concordant survivorship care is low.11 Barriers to adhering to guideline concordant care can include lack of patient knowledge, lack of provider knowledge surrounding the guidelines, increased risk of chronic disease, and lack of coverage to support these services.11–14 The results of this study suggest denials for screening for recurrence or second cancers are common in breast, Hodgkin lymphoma, head and neck cancer, colorectal cancer, and lung cancer. Denials are also common for mental health services and supportive care tests and services (i.e., fertility and dental health services). Additionally, individuals with gaps in coverage are less likely to receive cancer prevention screening and treatment. One can hypothesize that denials in survivorship care services may result in poorer outcomes, given the fact that the services are ultimately not covered and then potentially not performed or performed in a delayed fashion. Working through the denial process can create undo delays in cancer screening and preventive healthcare screening; it also provides stress for the patient and provider. Prior studies suggest individuals with gaps in health insurance coverage present with more advanced cancers, are less likely to receive recommended cancer treatment, and have a worse overall survival.
Dealing with insurance denials and prior authorization requirements for treatments and procedures has been associated with physician and provider burnout. It also contributes to physician dissatisfaction. In a recent survey of 22,276 physicians of internal medicine specialties by Shanafelt and colleagues,15 approximately one in three providers had signs and symptoms of burnout measured by the Maslach Burnout Inventory scale. While there are many factors associated with burnout, encountering insurance denials and authorization requirements places increased stress on patients and providers. It also increases the economic burden on medical practices themselves.16 Within our study, practices described a process to obtain insurance approval, although we did not explore the cost associated with these processes.
The conclusions of our study are limited to those common diseases where evidence-based survivorship care guidelines exist. As a result, it is unclear how common gaps in coverage exist for less common cancers or for those without clear guidelines for follow-up care. Additionally, the response rate was 22%, which may impact the generalizability of the results. Finally, within this analysis, quantitative assessments were distributed to individuals and practices familiar with survivorship care guidelines. This methodology was intentional; it was felt that the conclusions from this study, where gaps in survivorship care coverage were identified, would be applicable to other programs that may not have as much expertise around survivorship guidelines.
In conclusion, our study demonstrates that gaps in coverage for evidence-based survivorship care services exist, regardless of payer type or region of the country. In an effort to provide quality survivorship care and to reduce the burden on oncology providers and practices in working through denials and prior authorizations, there is a need for better advocacy with payers and improved policy to support quality guideline concordant care for cancer survivors.