The Consequences of Prior Authorizations

Posted on by

Like many clinicians, I would very much like to tell insurance companies how I really feel about their prior authorization policies, and peer-to-peer processes to get approvals needed for treating our patients.

Most of the time I resent the imposition on my time to craft detailed letters explaining my rationale for treatment. Some obstructionist tactics are particularly aggravating. For example, when I am asked to do a peer-to-peer call and find out on the call that the person on the other end is neither a peer (often a pharmacist) and more importantly that this person is not authorized to remedy the situation but only to arrange another call. Another tactic of asking me to write multiple letters at different stages of the authorization process is extremely annoying. All told, these authorization requests are becoming more frequent and further impinging on my free time.

Now it turns out a study has shown the harmful effects of these maneuvers for our patients:

Constant BD, de Zoeten EF, Stahl MG, et al. Delays Related to Prior Authorization in Inflammatory Bowel Disease. Pediatrics. 2022;149(3):e2021052501 (Thanks to Ben Gold for this reference)

In this retrospective study of 190 pediatric patients ((median age 14.5 years) with IBD initiating biologics at a tertiary care hospital, key findings:

  • Prior authorization and complicated prior authorizations (requiring appeal, step therapy, or peer-to-peer review) were associated with 10.2-day (95% confidence interval [CI] 8.2 to 12.3) and 24.6-day (95% CI 16.4 to 32.8) increases in biologic initiation time, respectively.
  • Prior authorizations increased the likelihood of IBD-related healthcare utilization within 180 days by 12.9% (95% CI 2.5 to 23.4) and corticosteroid dependence at 90 days by 14.1% (95% CI 3.3 to 24.8). 

In their discussion, the authors note that “in a recent survey conducted by the American
Medical Association, 94% of physicians reported that prior authorizations delay access to
necessary care, 90% perceived a negative impact on clinical outcomes, and 30% reported that a prior authorization led to a serious adverse event for a patient in their care.”

My take: Prior authorization policies usually delay needed care unnecessarily and lead to complications in children with IBD.

Related blog posts: