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Impact of a regimen-level prior authorization tool on provider adherence to clinical guidelines’ and cost savings in a Medicare advantage population
Heeseon Yeon, Rogelio Alberto Brito, Wenjing Kong, William Cavers, Allendre Mcgovern-Siembab, Anne Claussen, Kjel Andrew Johnson, Elisea Avalos-Reyes. Journal of Clinical Oncology, 2021-05-20
Topic: Risk, prevention and care in population studies
From April-December 2020, 279 PAs were submitted via NLX and 83% were automatically approved in real-time. PAs not automatically approved were deemed concordant after peer-to-peer consultations that led to NCCN concordance; no PA denials were made. In the first half of 2020, 2,690 MA patients with NSCLC were identified; 2,166 (81%) patients were defined as NCCN concordant. Beginning with and including the first treatment and for 30-days thereafter, total cost of care for concordant patients averaged $19,321 while non-concordant patients averaged $26,405, a statistically significant savings of $7,084 (p < 0.001). Preliminary findings with a MA NSCLC population suggest engaging oncology practices through an enhanced payer-provider collaboration and implementing an automated regimen-level precertification process with real-time NCCN updates can facilitate lower cost, and more efficient oncology care. Financial savings by encouraging providers to follow NCCN guidelines may lead to a 27% reduction in total cost of care with further proper adjustment on population bias; this may lead to similar findings in other cancer types. Future studies are needed to measure the long-term impact of this program on total cost of care for other care models and cancer types.
Key findings
- From April-December 2020, 279 PAs were submitted via NLX and 83% were automatically approved in real-time.
- PAs not automatically approved were deemed concordant after peer-to-peer consultations that led to NCCN concordance; no PA denials were made.
- In the first half of 2020, 2,690 MA patients with NSCLC were identified; 2,166 (81%) patients were defined as NCCN concordant.
- Beginning with and including the first treatment and for 30-days thereafter, total cost of care for concordant patients averaged $19,321 while non-concordant patients averaged $26,405, a statistically significant savings of $7,084 (p < 0.001).
- Preliminary findings with a MA NSCLC population suggest engaging oncology practices through an enhanced payer-provider collaboration and implementing an automated regimen-level precertification process with real-time NCCN updates can facilitate lower cost, and more efficient oncology care.
Why it matters
This study of a prior authorization tool in a Medicare Advantage lung cancer population found that 83% of requests were automatically approved and that guideline-concordant patients had lower total cost of care. It contains no research findings on treating, curing, or preventing Alzheimer's disease.
Study details
- Evidence strengthLow
How this study scored 29/100
Published in a peer-reviewed journal. Scored zero for study design, sample size, effect reported, studied in people and randomised / blinded because the record does not state it. We have no data on impact for its field and year, so that was left out: it earned 27 of the 94 points we could judge it on, which is 29 out of 100.
| Component | Points | Why |
|---|---|---|
| Journal tier | 7 / 10 | Tier 3 — peer-reviewed journal (Journal of Clinical Oncology) |
| Journal's citation record | 4 / 4 | Journal of Clinical Oncology: journal h-index 737 (OpenAlex, 2026-10-29) |
| Study design | 0 / 12 | No study design recorded — scores zero, not guessed (not stated in the record — scored 0) |
| Strength of evidence | 1 / 5 | Rated “low” in our summary |
| Peer-review validation | 10 / 10 | Peer-reviewed. Published as an article in a named peer-reviewed journal. |
| How recent | 3 / 5 | 2021 — within 6 year(s) of the newest study here |
| Sample size | 0 / 4 | Participant count not stated — scores zero (not stated in the record — scored 0) |
| Effect reported | 0 / 3 | No effect size reported — scores zero (not stated in the record — scored 0) |
| Studied in people | 0 / 3 | Not stated whether this was studied in people — scores zero (not stated in the record — scored 0) |
| Randomised / blinded | 0 / 2 | No randomisation or blinding stated — scores zero (not stated in the record — scored 0) |
| Times cited | 1 / 7 | Cited 2 times (OpenAlex, 2026-10-10) |
| Citations per year | 0 / 5 | 0.3 citations a year over 7 year(s) since 2021 |
| Impact for its field and year | — / 6 | No field-weighted citation impact (OpenAlex has none yet) — left out of this score |
| Cited by studies here | 0 / 6 | No other study in this library cites it |
| Still being cited | 0 / 4 | Cited 1 times in 2024–2026 (2026 still in progress; OpenAlex) |
| Senior author's track record | 0 / 4 | Last-listed author Elisea Avalos-Reyes: h-index 2 (OpenAlex, whole career) |
| Institution's track record | 0 / 3 | CVS Health (United States): institution h-index 97 (OpenAlex) |
| Multi-centre collaboration | 0 / 3 | OpenAlex lists 1 institution(s) in 1 country — scores zero (affiliation lists can be incomplete) |
| Indexed in PubMed | 1 / 2 | Not in PubMed, but has a DOI |
| Free to read | 0 / 2 | Behind a paywall — scores zero |
| Points | 27 / 94 | Scored on 19 of 20 parts. We have no data for the rest, so they are left out: 27 of the 94 points we could judge it on is 29 out of 100. |
| Total | 29 / 100 | — |
What each of these 20 components measures, and what this score is not →
Read the original
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Cite this study APA, Vancouver, BibTeX · download .bib or .ris
Built from the record alzhub holds for this paper, not looked up. Volume, issue and page numbers are not held in the record. The record names 8 authors; APA and Vancouver show the first six, BibTeX and the downloads carry all of them. Check the citation against the original before you use it.
APA 7th
Yeon, H., Brito, R. A., Kong, W., Cavers, W., Mcgovern-Siembab, A., Claussen, A., et al. (2021). Impact of a regimen-level prior authorization tool on provider adherence to clinical guidelines’ and cost savings in a Medicare advantage population. Journal of Clinical Oncology. https://doi.org/10.1200/jco.2021.39.15_suppl.1522
Vancouver
Yeon H, Brito RA, Kong W, Cavers W, Mcgovern-Siembab A, Claussen A, et al. Impact of a regimen-level prior authorization tool on provider adherence to clinical guidelines’ and cost savings in a Medicare advantage population. Journal of Clinical Oncology. 2021. doi:10.1200/jco.2021.39.15_suppl.1522.
BibTeX
@article{yeon2021-d16aaa1a,
author = {Yeon, Heeseon and Brito, Rogelio Alberto and Kong, Wenjing and Cavers, William and Mcgovern-Siembab, Allendre and Claussen, Anne and Johnson, Kjel Andrew and Avalos-Reyes, Elisea},
title = {{Impact of a regimen-level prior authorization tool on provider adherence to clinical guidelines’ and cost savings in a Medicare advantage population}},
journal = {Journal of Clinical Oncology},
year = {2021},
doi = {10.1200/jco.2021.39.15_suppl.1522},
url = {https://doi.org/10.1200/jco.2021.39.15_suppl.1522}
}
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