Prior Authorization: This Will Take Time

I recently read a newspaper article1 from my hometown that highlighted the ongoing frustration with the demands and failures associated with prior or pre-authorization (PA). The article described in some detail how the process of PA would be responsible for the delay in a particular person’s care. This delay would ultimately result in the patient having to settle for a less than optimal orthopedic outcome. Another family member would also experience a PA-centered problem that would lead to a change in the dose of her medicine as repeated attempts to reason with the insurance company went unfulfilled. I read this article with interest and perhaps mild surprise. Although our cancer clinic faces the burden of PA on a daily basis, it does take a rendering such as this to highlight how genuinely widespread the issues encountered with PA really are. An American Medical Association (AMA)–sponsored physician survey2 concerning the ramifications of PAs in 2017 recorded such outrageous findings as the PA process resulting in a delay or wait time of 3 to 5 business days. Ninety-two percent of those completing the survey reported delays in patient care. Seventy-eight percent recounted that PA can “at least sometimes lead to treatment abandonment,” and 92% reported that “PA can have a negative impact on patient clinical outcomes.” This same survey reported that 84% of physicians find the PA burden to be “high or extremely high,” and 86% commented that “PA burdens have increased over the past 5 years.” The history of PA is traced to the evolution of employee medical benefits. In an important semantic twist, PA emerged from the well-meaning cost-saving process of utilization review. It is now a requirement that is applied to a continually enlarging list of pharmaceuticals, medical equipment, and services. This, of course, was a measure to provide major cost savings and has been adopted by generally all stakeholders attached to the health care industry. Despite best intentions, however, it has been estimated that the PA process results in a cost to the health care system of $21 billion to $31 billion annually.3 This is again compounded by the realization of overwhelming administrative burdens along with overt delays in health care that potentially jeopardize patient access to that care. The PA process and its potential flaws were highlighted by the recent revelation of an Aetna medical director’s admission of not personally reviewing the majority of patient records in that insurance company’s PA process.4 This rather startling testimony has resulted in the examination