The Burden Imposed by Prior Authorization Requirements

Mr. Sahni

Results

The perceived overall approval rate of PAs, including appeals, was 88% for patients, 70% for providers and 73% for private payers. The proportion of respondents reporting overall time to approval taking more than five days was 37% for patients, 27% for providers and 15% for private payers. Patients reported the longest perceived wait times, but also the highest perceived approval rates and lowest perceived burden. Researchers noted that patients don’t usually directly participate in PA.

Clinical provider responses were grouped by reported medical specialties. The perception that overall time to approval (including appeals) took more than five days was highest for plastic surgery providers, at 67% of  respondents, and neurosurgery, at 64%. Specialties reporting the shortest overall approval time were physical and occupational therapy at 8%, with psychiatry/behavioral health/substance abuse at 19% and cardiothoracic surgery at 21%.

The researchers also looked at perceived approval rates and times for specific types of treatments, including those requiring appeal. For infused and injected medications, which are common in rheumatology, patients reported a perceived overall approval rate of 81% vs. providers, with a perceived approval rate of 67%. The rate of perceived approvals taking more than five days was 39% for patients vs. 31% for providers.

For oral medications, patients reported a perceived overall approval rate of 84% vs. providers perception of a 68% approval rate. Patients perceived the rate of approvals taking more than five days was 42% vs. providers’ perceptions of 32%.

Among respondents, provider staffing for PA work varied, with a median of 36% of providers reporting that more than three employees and individuals work on a median of 10 different PA cases weekly. Private payer respondents similarly reported a median of three employees working on a single PA case and that individuals were involved with a median of 20 different cases per week. Provider respondents reported a trend toward staff in lower licensure roles taking on more of the PA work.

Forty-two percent of provider respondents and 13% of private payer respondents identified PA requirements as a high contributor to burnout. The specific aspect most identified by both provider and private payer respondents as contributing to burnout was followup with the other party. Among provider respondents, 92% reported that PA caused delays in patient care, and 14% reported that care was delayed longer than two weeks.

The authors noted some limitations of their work. These include the use of self-reported data prone to recall bias and human error and convenience samples of respondents recruited with monetary incentives.