By NextBestFitEliminate prior authorization except for a short list
Keep only for a small published list of high-cost, high-variation services; review afterward instead (retrospective audit).
Draft decision:ChosenPhase 2: Wave 1: seniors, near-seniors, and childrenConfidence: medium · not yet reviewed
Keep prior authorization only for a short list; audit afterwards.
To review: Watch for more low-value care; depends on audit capacity.
Review ledgerHow this path connects
This path
Eliminate prior authorization except for a short list
Concrete changes if chosen
What would actually have to change in law, agencies, payment rules, or systems.
- Limit prior authorization to a published short list
- Fund post-payment audits
Effects
Each effect has its own page: the evidence, the case that it is or isn't a real cost, and whom it affects.
What it fixes
- Prior authorization delays and blocks care
Restricting prior authorization to a small published list and reviewing other care afterward removes care delays. It produces substantial administrative savings for clinics and insurers.
- About $1 trillion a year in administrative cost
Removing most prior authorization produces substantial administrative savings for clinics and insurers.
What it creates or worsens
- Low-value care and overtreatment
Removing most advance review risks more low-value care.
10 paths soften this
Evidence-based coverage decisionsLow-value care and overtreatmentChosenFeedback and clinician nudgesLow-value care and overtreatmentChosenModest copays with an income-based annual capUnderinsurance: covered, but can't afford to use itRejectedValue-based cost sharingUnderinsurance: covered, but can't afford to use itRejectedGlobal budgets for hospitalsU.S. prices are far higher than in other countriesChosenNo-fault compensation for medical injuryMalpractice system: slow, costly, and drives defensive medicineChosenNational health record and patient IDRecords don't follow patientsChosenSeparate public capital budget, planned regionallyUnder-investment in equipment and facilitiesChosenAccept somewhat slower adoptionSlower access to new drugs and technologyRejectedOnly flat, small charges on a few servicesCopays keep billing systems alive and still deter poorer patientsRejected - Makes performance and quality hard to oversee
Retrospective review requires audit capacity.
Who's affected
Who gains
- People with ongoing or specialist care needs
- Prior authorization delays and blocks care: Approval requirements delay treatment and can cause harm.
- Doctors, nurses, and other clinicians
- Prior authorization delays and blocks care: Approval requirements take time from physicians and staff.
- About $1 trillion a year in administrative cost: Time goes to billing and insurer rules instead of patients.
- People with employer coverage
- About $1 trillion a year in administrative cost: Premiums pay for the administration.
- Taxpayers and public budgets
- About $1 trillion a year in administrative cost: Public programs pay for it too.
- Hospitals, clinics, and care organizations
- Low-value care and overtreatment: Per-service payments reward additional low-value care.
- Drug and device makers
- Low-value care and overtreatment: They sell devices and tests used in low-value care.
Who loses
- Health insurers, brokers, and their shareholders
- Prior authorization delays and blocks care: They control treatment approval through prior authorization.
- About $1 trillion a year in administrative cost: Insurers, billing firms, and clearinghouses earn from the complexity.
- Low-value care and overtreatment: They pay for tests and treatments with little benefit.
- Health administration and software vendors
- Prior authorization delays and blocks care: They supply utilization-management services for approval requirements.
- Insurance and billing workers
- About $1 trillion a year in administrative cost: Their jobs exist because of the complexity.
- People with ongoing or specialist care needs
- Low-value care and overtreatment: Low-benefit tests and treatments expose them to harm.
- Taxpayers and public budgets
- Low-value care and overtreatment: They pay for tests and treatments with little benefit.
Where it has been tried
- Traditional Medicare: Uses very little prior authorization compared to Medicare Advantage.