Anti-VEGF Prior Authorizations Often Delay Care in Retina Practices

Sabin Dang, MD

Credit: The Retina Institute

Prior authorizations (PAs) for anti-vascular endothelial growth factor (VEGF) medications had an overall very high approval rate but caused delays in patient care, which could lead to vision loss, according to a new analysis in JAMA Ophthalmology.¹

Across 9 retina practices, and more than 2000 PA requests, >96% of PAs for anti-VEGF therapies were approved, but required a median of 100 minutes of clinic staff time and 57.4% of patients experienced a delay in care delivery.

“Though well-intentioned to mitigate rising costs, the use of current PA procedures is associated with an administrative burden on retina practices and health care systems overall,” wrote the investigative team, led by Sabin Dang, MD, The Retina Institute.

Anti-VEGF therapies have become the standard of care for numerous exudative retinal diseases in the past two decades, with US ophthalmologists performing nearly 3.6 million annual injections.² Rates are expected to increase simultaneously with expanded indications, novel therapies, and the aging population.

As a result, anti-VEGF medications mark a substantial proportion of Medicare expenditures, with aflibercept and ranibizumab representing 12% of total Medicare Part B spending.³ Cost-lowering utilization initiatives, including PA and step-therapy requirements, have typically involved anti-VEGF agents, given the significant cost difference between agents in the class.

However, PA has demonstrated unintended consequences including an increase in administrative burden, health care costs, and worse medical outcomes linked to delays in care delivery.⁴ Other specialties have investigated administrative burden and rates of PA, but no study, according to Dang and colleagues, has done so in anti-VEGF therapy usage.¹

Prospective data during the PA process were obtained from 9 retina practices across the US from January to June 2022 on the 3 most commonly used anti-VEGF medications: aflibercept, ranibizumab, and bevacizumab. Measurements included the overall rate of PA request approval, the reason for requesting PA, and the overall rate of care delay resulting from PA procedures.

Overall, 2365 intravitreal injection PA requests were logged from the clinical practices and 2225 met inclusion criteria. Of those included for analysis, 2140 (96.2%) requests were approved.

Notably, 40% (n = 863) of these PA approvals were approved on the same day as submission, while 59.6% (n = 1277) of PA requests delayed care delivery longer than 24 hours.

A granular analysis revealed that 23.9% of PA approvals were approved within 1 day, 15.9% within 2 to 3 days, 12.5% within 4 to 7 days, 26.3% within 8 to 31 days, and 12.4% within >31 days. Anti-VEGF-specific analysis showed PA approval rates were 99% (n = 405) for bevacizumab, 95% (n = 1185) for aflibercept, and 96% (n = 550) for ranibizumab.

Meanwhile, denials were observed for 3.8% (n = 85) of total PA requests, with step therapy being the reason in 76% (n = 65) of cases and uncovered diagnoses for the remaining 24% (n = 20) of cases.

Reauthorization for a previously utilized anti-VEGF medication was the most frequent indication for a PA request, accounting for 64.0% (n = 1423) of all requests.

Administrative burden was investigated in the analysis, revealing that 1742 hours were invested into processing all 2225 PA requests. Specifically, the median staff time spent to obtain each PA request was 100 minutes, with 0.54% of requests requiring >20 hours to obtain and 0.31% of patients waiting >1 month for successful approval.

In their conclusion, Dang and colleagues suggested the inability of the analysis to measure how care delivery delays could have translated to temporary or permanent vision loss but pointed to prior research on correlations between anti-VEGF delay and worse visual outcomes.

“Based on these 9 retina practices, the current application of PAs in retina practices does not appear to be a cost-effective measure and the authors believe its use warrants reconsideration,” Dang and colleagues wrote.

References

1. _{Dang S, Parke DW, Sodhi GS, et al. Anti-VEGF Pharmaceutical Prior Authorization in Retina Practices. JAMA Ophthalmol. Published online June 27, 2024. doi:10.1001/jamaophthalmol.2024.2217}
2. _{Glasser DB, Parikh R, Lum F, Williams GA. Intravitreal Anti-Vascular Endothelial Growth Factor Cost Savings Achievable with Increased Bevacizumab Reimbursement and Use. Ophthalmology. 2020;127(12):1688-1692. doi:10.1016/j.ophtha.2020.06.012}
3. _{Patel S. Medicare Spending on Anti-Vascular Endothelial Growth Factor Medications. Ophthalmol Retina. 2018;2(8):785-791. doi:10.1016/j.oret.2017.12.006}
4. _{Resneck JS Jr. Refocusing Medication Prior Authorization on Its Intended Purpose. JAMA. 2020;323(8):703-704. doi:10.1001/jama.2019.21428}