The landscape of health care in the United States is witnessing a significant shift, particularly regarding the contentious practice of prior authorization. Major health insurers, including UnitedHealthcare and CVS Health’s Aetna, are pledging to refine and reduce this practice, which has drawn ire from both patients and providers for its role in delaying care and complicating access to necessary treatments.
Prior authorization requires patients to obtain approval from their insurance before receiving certain medical services, prescription drugs, or diagnostic tests, like imaging exams. Insurers argue that this process helps prevent overuse of services and ensures patients receive appropriate care. However, the reality on the ground has become increasingly convoluted, with many doctors asserting that the prevalence of these requirements has ballooned in recent years.
The tragic incident involving the shooting of UnitedHealthcare CEO Brian Thompson in December illuminated widespread frustration over insurance hurdles like prior authorization. This event catalyzed public discussions about the burdens imposed by insurers, prompting various stakeholders to seek reforms.
Amidst mounting calls for change, prominent figures in health care, such as Dr. Mehmet Oz, have publicly denounced prior authorization as a significant obstacle to effective patient care. During his Senate confirmation hearing in March for the Centers for Medicare and Medicaid Services, he labeled the practice a “pox on the system,” exemplifying the growing consensus that reform is urgently needed to alleviate the administrative costs and delays associated with insurance claims.
In a recent announcement, health insurers committed to several reforms aimed at streamlining the prior authorization process. By the end of next year, they plan to standardize electronic prior authorizations, which should help reduce delays. Additionally, insurers will limit the types of services requiring prior approval and agree to honor pre-authorizations from previous insurers for a defined period when patients switch plans. Such measures signal a move toward a more patient-friendly approach in an environment notoriously characterized by red tape.
The call for reform comes against a backdrop of escalating health care costs. Research indicates that as the costs of services, particularly prescription drugs, lab tests, and imaging exams, continue to rise, the reliance on prior authorization has intensified. Michael Anne Kyle, an assistant professor at the University of Pennsylvania, highlights a critical paradox: “We’re sort of trapped between care being unaffordable and these non-financial barriers and administrative burdens growing worse.”
According to a 2023 study by the health policy research organization KFF, nearly all customers of Medicare Advantage plans must navigate prior authorization for certain services, primarily those that incur significant costs. The study also uncovered that insurers denied about 6% of all prior authorization requests, further complicating patients’ access to timely care.
Real-world anecdotes underscore the challenges posed by prior authorization. Dr. Ashley Sumrall from Charlotte, North Carolina, notes a rising number of prior authorization requests for routine diagnostic exams like MRIs, which are crucial for monitoring treatment efficacy in her oncology practice. The delays tied to approval processes can have dire consequences, allowing diseases to advance without timely intervention and heightening patient anxiety as they await decisions on crucial imaging.
Sumrall candidly addresses the phenomenon known as “scanxiety,” wherein patients become overwhelmed with worry about whether their condition is stable and whether their insurance will cover necessary scans. Such emotional tolls underscore the urgent necessity for reform in the prior authorization landscape.
The existing disparity among insurers—with each organization enforcing its own process and requirements—exacerbates the challenges of timely and efficient patient care. “For years, the companies have been unwilling to compromise, so I think any step toward standardization is encouraging,” Sumrall asserts, reflecting the widespread hope that recent commitments will ease the burdens associated with prior authorization.
The implications of these reforms extend beyond individual plans; they promise to touch on coverage through employer-sponsored insurance, individual markets, Medicare Advantage plans, and Medicaid programs. As these commitments take shape, the health care system may begin to shift toward a more patient-centric model, one that facilitates access to care rather than obstructs it.
