By NextBestFitPrior authorization delays and blocks care
Insurers require approval before many treatments. Physicians say it delays care and causes harm; practices spend about 12 hours a week on it.
Evidence
- 94% of physicians say prior authorization delays necessary care; 24% report a serious adverse event; 78% say patients abandon treatment.Sources: American Medical Association (2024)
Who's affected
Who is hurt
- People with ongoing or specialist care needs: Approval requirements delay treatment and can cause harm.
- Doctors, nurses, and other clinicians: Approval requirements take time from physicians and staff.
Who gains while it lasts
- Health insurers, brokers, and their shareholders: They control treatment approval through prior authorization.
- Health administration and software vendors: They supply utilization-management services for approval requirements.
Under your mix of paths
Paths that fix or soften it
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Root causes
- Insurers' cost-control incentive
- Lack of trusted, shared evidence rules
Related costs
Open questions
- Should prior authorization exist? If so, for which services and decided by whom?
Solution paths (2)
Open a path for what it fixes, what it creates or worsens, who gains and who loses, precedents, and how it connects to other paths. See all paths as a decision tree.
Exempt clinicians with high approval rates; require real-time electronic decisions; ban prior authorization for routine and chronic care.
- +Prior authorization delays and blocks care
- −Raises spending or loosens control over it
- −Solves only part of the problem
Keep only for a small published list of high-cost, high-variation services; review afterward instead (retrospective audit).
- +Prior authorization delays and blocks care
- +About $1 trillion a year in administrative cost
- −Low-value care and overtreatment
- −Makes performance and quality hard to oversee