How Prior Authorization Impacts Patient Access to Care

Why Do Payers Use Prior Authorization?

Prior authorization is a cost and utilization management strategy employed by health payers and health plans whereby patients must obtain health plan approval before receiving a healthcare service or treatment, according to KFF.

“This allows the plan to evaluate whether care is medically necessary and otherwise covered,” KFF says on its website. “Standards for this review are often developed by the plans themselves, based on medical guidelines, cost, utilization, and other information.”

Prior authorization can often include step therapy, a system by which patients and providers must first exhaust lower-cost treatment options before being approved for the preferred higher-cost treatment.

The process by which patients, and usually their providers, obtain prior authorization can depend on the health plan and the requirements it has set up. According to physicians, this process can create significant administrative burden.

According to the 2023 AMA survey, 88 percent of physicians describe the workload linked to prior authorization as high or extremely high, and 35 percent have dedicated staff members who focus solely on prior authorizations. Respondents reported that they complete an average of 45 prior authorizations weekly, amounting to nearly two business days' worth of work.

For their part, health payers acknowledge that prior authorization can be burdensome, especially when it’s a paper-based system. But AHIP, the trade group that represents the nation’s health payers, doubles down on the role prior authorization plays in reducing low-value care.

“Under the supervision of medical professionals, prior authorization can reduce inappropriate care by catching unsafe or low-value care and targeting where care may not be consistent with the latest clinical evidence – both of which can contribute to potential harm to patients and unnecessary costs,” AHIP says on its website.

But physicians aren’t convinced. In the AMA survey, 86 percent of physicians said prior authorization can actually lead to healthcare overutilization because patients must first employ less effective treatments as a part of step therapy. Overutilization included the use of ineffective treatments in step therapy (64 percent), additional office visits (62 percent), and ED visits (46 percent).

What’s more, physicians say prior authorization criteria—the parameters by which a payer approves a treatment or therapy—aren’t always rooted in the data. The AMA survey showed that 43 percent of providers find prior authorization criteria sometimes align with evidence-based studies, while 31 percent said they rarely or never do.

But perhaps the most notable roadblock put in place by prior authorization is the impact on the patient and patient access to care.

Prior Authorization’s Limits on Patient Care Access

Prior authorization can impact patient access to care by creating delays, healthcare providers report. In the AMA survey, 42 percent said their patients often see care access delays, and 37 percent said they sometimes do.

These problems have been reported by other clinicians, too. In a report published in Inflammatory Bowel Diseases, Mayo Clinic gastroenterologists Francis A. Farraye, MD, MS, and Lauren P. Loeb, MD, said that prior authorizations have adversely impacted their patients.

"In this high-risk patient population, step therapy requirements and the failure of payers to recognize updated IBD treatment pathways can cause treatment delays or denial of care. And treatment delays and denial can lead to a recurrence of symptoms, disease progression and increased costs,” Farraye said in a 2023 news release about the report.

In an analysis of prior authorizations for 42 inflammatory bowel disease (IBD) patients, the pair found that the mean length of time from prescription to prior authorization approval was 5.8 days; the longest length of time observed was 34 days, they said. About a quarter of patients (26 percent) wait more than two business weeks for approval.

This problem was worse for noncommercial payers, like Medicare and Medicaid, Farraye and Loeb found. While the average wait time for patients with commercial insurance was six days, those with noncommercial insurance had to wait an average of 22 days for approval. This could exacerbate sociodemographic health disparities, the pair pointed out.

Those long wait times could result in the escalation of care, the data furthered. Among the 26 percent of patients waiting two business weeks for approval, three required steroids and one required hospitalization.

Patients may also abandon their care when the wait for prior authorization approval becomes too long. In the AMA survey, 26 percent of physicians said prior authorizations often lead to abandoned treatment plans, and 52 percent said they sometimes do.

Prior Authorization Solutions

Efforts to reduce low-value care are valid, but the reported impact prior authorization has on patient access to care—and, by extension, outcomes—highlights the need for a better system.

According to AHIP, electronic prior authorization (ePA) can speed up the time to medical decision-making. Seven in 10 (71 percent) of providers who used ePA tools said their patients got care faster than when they completed paper-based prior authorizations. The median time to a decision fell from 18.7 hours to 5.7 hours.

Industry stakeholders are also looking at reworking the concept of prior authorizations, not just the tools used to complete them.

In February 2023, the CMS Advancing Interoperability and Improving Prior Authorization Processes proposed rule introduced new requirements for payers to improve patient data sharing and for streamlining authorizations.

Particularly, the rule pitched the idea of making authorization decisions available to patients via application programming interface (API), listing prior authorization requirements on an API, and outlining the specific reasons behind a prior authorization denial.

CMS also proposed adding an ePA measure to the Promoting Interoperability performance category of the Merit-based Incentive Payment System (MIPS).

CMS proposed the rule on December 6, 2022, left it open for comment until March 13, 2023, and, as of publishing date, is evaluating public response.

Some payers are taking matters directly into their own hands. In August 2023, Cigna Healthcare said it would remove prior authorization requirements for nearly a quarter of its medical services.

“Our goal is to help keep patients safe, improve health outcomes, and make care more affordable, and this important step will enable us to do that while removing administrative burdens on the healthcare system,” David Brailer, MD, executive vice president and chief health officer of The Cigna Group, said in the press release.

“We’ve listened attentively to our clinician partners and are deliberately making these changes as a result. We will continue to hold ourselves accountable for this important work and look forward to building on this momentum in the future.”