Dr. Rupal O'Quinn is a cardiologist in Philadelphia who is affiliated with both Penn Presbyterian Medical Center and Pennsylvania Hospital. She graduated from Rutgers Robert Wood Johnson Medical School with her medical degree. In this video Dr. O'Quinn speaks about her research in Cardiac Magnetic Resonance in Cardio-Oncology: Advantages, Importance of Expediency, and Considerations to Navigate Pre-Authorization.
Link to Abstract-
As the scope of cardio-oncology expands dramatically, both in terms of the number of people impacted and the sorts of therapy it involves, diagnosing acute and late cardiotoxicity from cancer therapeutics has become increasingly crucial. Cardiac magnetic resonance (CMR) is a tool that can provide unequaled diagnostic information when compared to other imaging modalities, however due to the need for insurance pre-authorization, its use is frequently delayed, at the price of patient care. This paper discusses when CMR should be used as a diagnostic tool and gives examples of diagnoses that are more likely to be approved by insurance companies. It also contains specific cardio-oncology diagnoses and questions to assist the clinical cardio-oncologist with the pre-authorization process.
• While evolving cancer medicines improve patient survival, they can also cause cardiotoxicity.
• CMR can help diagnose, prognosticate, and provide insight into cardiotoxicity management.
Why Insurance companies' use of pre-authorization for CMR frequently results in delays in patient care.
• Insurance payers and providers must be educated and advocated for in order to overcome these barriers.
Cardio-oncology is a rapidly growing discipline that is constantly evolving. Part of this rapid growth can be attributed to breakthroughs in oncology, which have resulted in new treatments that are raising survival and cure rates. Many innovative therapies are linked to cardiovascular side effects. Anthracyclines were once thought to offer the highest risk to patients, although this risk was thought to be "manageable" if the dose was kept below a certain threshold (1). Following that, even at modest dosages, anthracyclines have been shown to cause significant cardiotoxicity. Newer medications feature a variety of cardiac adverse effects, ranging from severe hypertension with tyrosine kinase inhibitors to life-threatening myocarditis with immune checkpoint inhibitors (ICIs), and severe shock-like dysfunction with chimeric antigen receptor T cell therapy, notwithstanding their benefits (2). Chemotherapy–related cardiac dysfunction (CTRCD) can arise early in the course of cancer treatment (3) and can be delayed in the case of radiation therapy, especially when radiation fields include incidental dosage to cardiac tissues or the major arteries (4). Furthermore, newer evidence suggests a substantial risk of major adverse cardiovascular events (MACE) in the first few years after cardiac radiation exposure (5). Both the cardiovascular and oncologic communities are concerned about the necessity to diagnose these toxicities quickly and accurately. It is predicted that 30% of all cancer patients will experience some type of cardiovascular problem as a result of their treatment; additionally, cardiovascular illness is the primary cause of morbidity and mortality in the years after cancer treatment (6).
The changing paradigm of cancer as a chronic disease requiring long-term follow-up for persistent cardiovascular harm necessitates long-term follow-up. As more cancer patients are treated, remission is achieved, and survivorship begins, it is necessary to identify those who are at risk and develop ways for monitoring long-term cancer therapy–related cardiac illness. The number of cancer survivors in the United States is expected to rise by approximately 11 million in the next 25 years, from 15.5 million in 2016 to 26.1 million in 2040. Notably, the percentage of survivors aged 65 and up will rise from 61 percent to 73 percent. Only 18% of cancer survivors will be between the ages of 50 and 64 years old by 2040, and only 8% will be under the age of 50. As a result, the majority of survivors are older people who may have had cardiotoxic therapy but are still at risk for cardiovascular disease as a result of aging or other concomitant conditions. This is the so-called "silver tsunami" demographic, which will surely necessitate cardiovascular imaging and treatment options (7).
CMR imaging is an important tool for detecting early and late cardiotoxic effects (8); however, there are various obstacles to getting these tests done on time, which can have an impact on patient care both in the acute and survival stages. Pre-authorization burdens imposed by insurance companies, in particular, have been noted as having an increasingly negative impact on patient treatment (9). We collaborated with members of the American College of Cardiology (ACC) Cardio-Cancer Section to identify key barriers to CMR adoption in oncology patients. Most cancer patients are likely to be affected during the early stages of treatment with newer, more effective medicines, as well as throughout follow-up as survival rates continue to rise.
This paper describes the scale of the problem, the circumstances in which CMR is most useful, and justifications for removing onerous pre-authorization requirements that delay therapy and place a significant burden on practicing physicians, particularly in the field of cardio-oncology and cancer care. When ordering a CMR for a cardio-oncology patient, we also go through useful nomenclature and indications.
The Pre-authorization Burden's Scope
The use of pre-authorization for testing as a cost-cutting tool has exploded in recent years. Many practices are forced to repeatedly request testing or medications for their patients, only to be denied. Insurance companies frequently create their own guidelines to make coverage determinations, which are often not transparent or publicly available, forcing many practices to request testing or medications for their patients, only to be denied. The American Medical Association (AMA) conducted a web-based poll in 2020 of 1,000 practicing physicians who offer patient care for more than 20 hours per week; 40% were primary care physicians and 60% were specialists. Almost 86 percent of practices said the administrative burden of prior authorization requests has increased in the last five years, and 86 percent said the burden is "very or extremely high." A medical practice completes 33 prior authorization requests per physician each week on average, which take 14.4 hours to process, and 30% of physicians hire staff to focus only on prior authorizations. Nearly 26% of physicians wait an average of 3 to 5 days for authorization, and 7% wait more than 5 days (9).
The fact that a delay in therapy is linked to unfavorable outcomes is a major worry for physicians caring for cancer patients suspected of having cardiotoxicity. The following is taken from the same poll (nine):
Pre-authorization delays are said to have caused substantial patient damage in 24% of cases.
Unnecessary hospitalizations were reported by 16 percent of respondents.
Pre-authorization, according to 91% of respondents, caused a delay in receiving care.
Pre-authorization prompted 74 percent of patients to forego recommended care because to the delay.
The burden of pre-authorization has also piqued the ACC's interest. Members who were practicing cardiologists were questioned how pre-authorization was affecting their practice patterns in response to an ACC Advocacy call to action. Several themes emerged from the data (H. McCants, personal communication, May 2019):
Peer-to-peer conversation was required in 25% of cases after the initial prior authorization denial.
In 42 percent of denials, it was suggested that a new (less expensive) test be performed instead of the original request;
45 percent of instances required more than 30 minutes on the phone to settle, and 30% of cases required the ordering physician's intervention to handle the authorization.
60 percent of filed cases resulted in care being delayed or rescheduled.
Despite the fact that these data were not particular to CMR, CMR was widely mentioned as a test that required pre-authorization.