Prior Auth Requirements Did Not Reduce Costs in Total Hip Arthroplasty

SAN DIEGO — Prior authorization (PA) requirements for patients undergoing primary total hip arthroplasty did not reduce costs, but did delay procedures, according to a prospective, single-center study.

Among 3,922 patients with single-payer commercial insurance, there was no difference in the mean claims cost from initial request date to date of surgery for the group who had a PA requirement and those who did not ($318 vs $302, P=0.430), reported Paul Maxwell Courtney, MD, of the Rothman Orthopaedic Institute in Philadelphia, at the American Academy of Orthopaedic Surgeons annual meeting.

Furthermore, patients in the PA group were found to have significantly lower preoperative hip dysfunction and osteoarthritis outcome scores for joint replacement compared with those in the non-PA group (48.1 vs 49.7, P=0.021) and significantly longer duration from initial surgery request date to date of total hip arthroplasty (40.4 days vs 38.7 days, P=0.023).

Co-author Elizabeth Abe, a medical student, told MedPage Today that the findings raise questions about why some patients have to deal with PA requirements. “Compared to patients who didn’t have any kind of prior authorization or rules that they had to satisfy, there was no cost difference,” she said. “No patients in our study were [ultimately] denied surgery, and they all ended up having surgery. What really is the point of all this?”

PA continues to be a hot topic among physicians, who say requirements are burdensome and hurt patient care. New federal regulations may provide some relief, but physicians say their impact is limited, and they don’t go far enough.

In the context of total hip arthroplasty, insurers with PA may require patients to undergo multiple forms of conservative treatments, such as physical therapy and steroid injections, before surgery is approved, Abe said. Among the patients in this study, “nobody went through all of these hurdles and was told, ‘You did all this, and you still can’t have surgery.’ Everybody ended up having surgery.”

Abe cautioned that “we might have underestimated the administrative burden of this” compared with institutions that may not have Rothman’s resources, such as a dedicated PA team. “Our surgeons know what they need to put into the progress and clinic notes to get by these automated [PA] processes,” she said.

Adam J. Rana, MD, chair of advocacy and health policy for the American Association of Hip and Knee Surgeons, told MedPage Today that a survey of members of the association found that “over 90% of our membership has seen an increase in burden in [PA] over the last 5 years, and over 90% of our members think that or feel that prior authorization has a negative impact on their patients and their care.”

He agreed with Abe that the study findings may underestimate the true burden of PA in areas such as delays to surgery. Rothman has “figured out ways to streamline the process,” he said. “That’s not true throughout the rest of the country. So, the results here are probably magnified.”

At his own clinic, Rana noted, two full-time employees handle PA requirements for five surgeons.

For this study, the researchers included a consecutive series of 3,922 patients undergoing primary total hip arthroplasty with commercial insurance from a single payer from 2020 to 2022. Of these patients, 72.4% required PA.

The patients in the PA and non-PA groups were similar: mean age was 59.6 and 66, 46.6% and 53% were women, 75.4% and 81.5% were white, and mean body mass index was 30.1 and 29.4, respectively.

PA was required for 59.1% of inpatient procedures and 40.9% of outpatient procedures. Inpatient procedures were denied but outpatient ones were approved in 3.52% of PA cases and 2.96% of non-PA cases.

Surgeries were denied on initial request in 1.48% of PA procedures (0.60% required peer-to-peer consultations) and none of the non-PA procedures. There was no difference in the mean claims cost in the year prior to total hip arthroplasty ($316 vs $318, respectively, P=0.760).

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