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The Intersection of Insurance With Shared Decision Making for Advanced Prostate Cancer Care

Multiple medications have been approved for metastatic castrate-resistance prostate cancer (mCRPC). Clinicians are tasked with navigating the side effects, uncertain comparative efficacy, and patient preferences and values to create a treatment plan; this plan, however, must be approved by the insurance company. Herein, we qualitatively examine the relationship between the shared decision-making (SDM) process and insurance approval/authorization.

METHODS:
Semi-structured interviews with medical oncologists and urologist who treat patients with mCRPC within the United States were performed. Interviews were transcribed and iteratively content coded. Central themes related to the interaction between insurance companies and implemented mCRPC treatments were summarized.

RESULTS:
Twenty-seven physicians (19 oncology, 8 urology) were interviewed. Common themes amongst participants included treatment delays, financially motivated changes to treatment plans, dedicated staff for the insurance process, and frequent requirement of third-party financial assistance. While 16 (59%) stated a cost-agnostic approach to selecting their initial recommendation, 23 (85%) mentioned the insurance auth/approval process can change the initial treatment plan. 18 (67%) have dedicated help to navigate the insurance auth/approval process. 19 (70%) stated that they have patients who changed treatment due to out-of-pocket costs; 10 (37%) mentioned these changes happening at the beginning of the year due to deductibles or insurance changes. 8 (30%) explicitly mentioned having met delays in treatment initiation due to the auth/approval process; as stated by one physician “[when requesting enzalutamide after abiraterone failure], they usually delay authorizing the drug, unacceptably long for weeks.” Figure 1 summarizes the relationship between SDM and insurance auth/approval.

CONCLUSIONS:
The insurance process can interfere with SDM and lead to treatment delays and high financial burden for patients. Future research should quantify the financial impact of the considerable resources required to navigate the current approval/authorization process on oncology practices and on patients. These data can guide policymakers to improve the process for all involved parties.

Rand Wilcox Vanden Berg, Karissa Tu, J. Kelly Davis, Ada Campagna, Sharron Docherty, Daniel George, Peter Ubel, and Deborah Kaye

Source: Berg, R.W. et al. (2023) ‘MP54-11 the intersection of insurance with Shared Decision Making for Advanced Prostate Cancer Care’, Journal of Urology, 209(Supplement 4).