Healthcare Approvals: Reviewing and Updating Prior Authorization Policies

Rethinking Healthcare Approvals: The Case for Reviewing and Updating Prior Authorization Policies

In the labyrinth of modern healthcare, one of the most contentious and complex challenges facing providers, payers, and patients alike is the prior authorization (PA) process. Defined as the requirement for a healthcare provider to get a health insurer’s consent to prescribe medication or supply a medical service, prior authorizations were initially meant as a cost-control measure.

For all its well-intentioned beginnings, the PA process has ballooned into a daunting bureaucratic task littered with inefficiencies, financial burdens, and, in some cases, barriers to patient care access. This blog post explores the evolving problems of prior authorization and why a policy overhaul is not just a suggestion but a necessity in delivering efficient and compassionate healthcare.

The Evolution of Prior Authorization in Healthcare

Initially, prior authorizations were a limited tool to ensure patient safety, efficacy, and cost-effectiveness. This meant to curb unnecessary healthcare costs by requiring providers to get insurer approval before providing a service; the system aimed at preventing adverse drug interactions, tracking prescription opioid distribution, and guiding patients towards generic options or non-opioid therapies whenever suitable.

However, with time, what started as a selective tool designed to safeguard health plans and patients became a prerequisite for an astonishing number of medical services, leading to an exponential increase in administrative burden and costs for healthcare systems. A gateway to entry for services, prior authorization is now omnipresent, with up to 88% of doctors reporting that the process has influenced a patient’s clinical course, often leading to delays in care or abandonment of treatment.

The Current State of Prior Authorization: A Logistical Nightmare

For clinicians and healthcare administrators, prior authorizations have become arduous, transforming patient care into a logistical nightmare fraught with complex phone calls, documentation, and appeals. This detracts valuable time and resources from patient care, contributing to physician burnout and escalating costs.

A recent report by the American Medical Association revealed that physicians spend an average of 16.4 hours per week on administrative tasks associated with insurance, of which a significant portion is devoted to prior authorization requirements. With the average practice completing 31 prior authorizations per physician per week, it’s easy to see how this back-and-forth approval dance can quickly amplify into a backlog that considerably delays patient treatment.

The Unseen Toll on Patient Care and Outcomes

The unseen collateral damage of prior authorizations is the impact on patient care. Delays due to the administrative hurdles in obtaining prior authorizations are not just frustrating; they can be harmful. For patients awaiting services, especially those with chronic or severe illnesses, delays in treatment can mean worsening of symptoms, disease progression, and reduced chances of favorable clinical outcomes.

The urgent review and policy reform case is underscored by countless stories of patients whose health was deteriorating while their providers navigated the labyrinth of prior authorizations. These accounts reflect the human cost of a process gone awry and the systemic problems in current healthcare practices.

The Economic Burden of Approval

Beyond the personal toll, prior authorizations have a considerable financial impact on healthcare providers and their patients. The costs can be direct, in the form of administrative fees and additional staffing required to manage the process, as well as indirect – the fees and consequences associated with delayed or foregone patient care.

Studies have shown that the pre-authorization system in the United States alone costs the healthcare industry $23-$31 billion annually, averaging around $86,000 per year for every physician. These costs are substantial and passed on to patients through increased medical expenses and insurance premiums, creating a complex cycle of financial burdens.

Addressing the Policy at Its Core

Addressing the prior authorization dilemma will require a multi-faceted approach, including policy changes that streamline the approval process while maintaining the original objectives of managing care costs and quality. Proposals have been put forward by professional groups, legislative bodies, and even the insurance industry, suggesting that change is necessary and feasible.

Central to these reforms is the call for transparency in the criteria for prior authorization, standardization of the approval process, leveraging technology solutions, and implementing real-time approval systems to reduce wait times. Furthermore, a critical look at the services and medications for which prior authorizations are required is needed, ensuring that the process is only applied when necessary.