Physicians say that toll from prior authorization exceeds alleged benefits 

March 16, 2023 – The approval process health insurers impose on medical services or drugs is generating a toll that exceeds the purported benefits, according to a physician survey released today by the American Medical Association and shared in a letter to federal health officials. While health insurers claim prior authorization requirements are used for cost and quality control, a vast majority of physicians say authorization controls lead to unnecessary waste and avoidable patient harm. 

According to the AMA survey, more than four in five physicians (86%) reported that prior authorization requirements led to higher overall utilization of health care resources, resulting in unnecessary waste rather than cost-savings. More specifically, about two-thirds of physicians reported resources were diverted to ineffective initial treatments (64%) or additional office visits (62%) due to prior authorization policies, while almost half of physicians (46%) reported prior authorization policies led to urgent or emergency care for patients. 

The health insurance industry maintains prior authorization criteria reflect evidence-based medicine, but physician experiences call into question the clinical validity of insurer-created criteria that lack transparency. Only 15% of physicians reported that prior authorization criteria were often or always evidence-based. 

Other critical concerns highlighted in the AMA survey include: 

  • Patient Harm – One-third of physicians (33%) reported that prior authorization led to a serious adverse event for a patient in their care, including hospitalization, permanent impairment, or death. 
  • Bad Outcomes – Nearly nine in 10 physicians (89%) reported that prior authorization had a negative impact on patient clinical outcomes. 
  • Delayed Care – More than nine in 10 physicians (94%) reported that prior authorization delayed access to necessary care. 
  • Disrupted Care – Four in five physicians (80%) said patients abandoned treatment due to authorization struggles with health insurers. 
  • Lost Workforce Productivity – More than half of physicians (58%) who cared for patients in the workforce reported that prior authorizations had impeded a patient’s job performance. 

In addition, a significant majority of physicians (88%) said burdens associated with prior authorization were high or extremely high. This costly administrative burden pulls resources from direct patient care as medical practices complete an average of 45 prior authorizations per physician, per week, which consume the equivalent of almost two business days (14 hours) of physician and staff time. To keep up with the administrative burden, nearly two in five physicians (35%) employed staff members to work exclusively on tasks associated with prior authorization. 

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