Imagine this scene: You are a cancer patient already navigating fear and uncertainty around your treatment, when you inexplicably cannot access the care recommended by your cancer doctor. This turns out to be because of a perverse hurdle imposed by your insurance company — called a prior authorization — that ends in a denial of care.
You would not be alone: More than 1 in 5 (22%) cancer patients report not getting care recommended by their doctor because of these delays or denials. If you’re lucky enough to live in one of just two states — Washington and, as of this month, New Jersey — you are more protected from these delays. If you live elsewhere, you might not be. More states, and the federal government, need to follow Washington’s and New Jersey’s lead, because both patients and clinicians are actively harmed by insurance companies using prior authorization to put up barriers to needed care.
Prior authorization is a process by which health insurance companies require preapproval for clinical treatments or services before covering their costs. While billed as a way to help clinicians provide care that is both evidence-based and necessary, in reality, prior authorizations can block necessary care. Instead, they seem focused on increasing profits for insurance companies.
A 2023 study in JAMA Network Open found that 73% of cancer patients who faced prior authorization experienced a delay in care of two weeks of more. Most patients (67%) had to become personally involved and 20% spent 11 or more hours on the process to get the care they needed. The experience was rated as bad by 40% and as horrible by 32% of patients, significantly increasing anxiety and delaying needed care where timeliness especially matters.
As frontline physicians and public health leaders, we have seen these failures firsthand.
One of us, Tina, had a patient who tried for four months to get outpatient imaging that would determine if she needed further treatment for her endometrial cancer. Through prior authorization, her insurance company denied her twice. The imaging was finally done when she was admitted to the hospital — and it showed, too late, that her cancer had spread. She’d also developed a pulmonary embolism: a life-threatening blood clot in the lungs — a known complication of untreated cancer. She now needs lifelong anticoagulation treatment (with complicated monitoring and risks for bleeding) while battling newly advanced cancer, both of which could have been prevented with more timely care, had her imaging not been blocked.
Another patient was denied access to her daily asthma medication, despite having been on it since childhood — because it was newly classified as a nonformulary medication. She had to first try a generic version and demonstrate it to be unsuccessful, before she could get back on her tried-and-true medication. She ended up being hospitalized for 49 days for life-threatening breathing problems while trying out the generic version — a completely avoidable set of events.
Decisions to deny care are often made without physician review and can be inappropriate. In a 2022 American Medication Association (AMA) survey, 31% of physicians reported that prior authorization criteria are rarely or never evidence-based, and another 43% said they are only sometimes so.
Additionally, a 2022 report by the Office of the Inspector General shockingly found that 13% of prior authorization denials by Medicare Advantage plans were for “services that our physician reviewers determined were medically necessary” and “likely would have been approved for these beneficiaries under original Medicare” rules.
Americans already wait long periods to see their clinicians and visits are too short to comprehensively address their concerns — while clinician burnout, shortages, and early exits are at epidemic levels. Streamlining the crushing administrative paperwork and removing unnecessary roadblocks to care will open up valuable time for clinicians to spend with their patients.
Currently, the AMA reports that clinical teams spend nearly two full business days (14 hours) per week completing prior authorizations, and 35% of practices have had to hire staff to specifically take on this work.
The impacts for patients are alarming: 94% of clinicians surveyed by the AMA in 2022 said prior authorizations have delayed care, and 80% say they have led patients to abandon treatment. Nearly half (46%) of physicians say they led to urgent or emergency care, and a quarter (25%) report that they led to a patient’s being hospitalized. Nearly 1 in 5 (19%) physicians report they led to a life-threatening event, while nearly 1 in 10 (9%) report that the process led to permanent disability or death. All of these outcomes could have been prevented.
Luckily, there have been promising legislative efforts at the state level to curb this.
After Washington in 2023, New Jersey just became the second state to pass legislation that reforms prior authorization for state-regulated health plans.
The recent New Jersey victory was fueled by an unprecedented joint mobilization of clinicians and patients, who together sent thousands of letters to legislators, strengthening the negotiating power of the Medical Society of New Jersey and other advocacy groups.
The New Jersey legislation — the most comprehensive of its kind — will require:
- Prior authorization turnaround time for medications to be reduced from 15 days to 24 hours for urgent requests, defined by the treating physician;
- Actual peer-to-peer conversations for denials involving a physician from the same specialty or who has direct experience with the treatment within the past five years; and
- Transparency — for the first time, insurance companies will have to share data around prior authorizations, such as number of denials and reasons.
We believe we finally are at a tipping point on this critical issue, with 29 other states with active bills on prior authorization reform, including California (where one of us, Devika, served as acting surgeon general in 2022).
But federally, such efforts have been slow. The Centers for Medicare and Medicaid Services proposed a rule to restrict prior authorization in 2020, but it was withdrawn after heavy lobbying by the insurance industry. A Senate bill failed to gain traction in 2023 due to cost estimates from the Congressional Budget Office that the AMA called “flawed.”
On Jan. 17, CMS published a new rule around prior authorizations that, if implemented, will require transparency on denials and shorten response time for urgent prior authorizations to 72 hours. However, these changes won’t go into effect until 2027. Additionally, the new CMS rule does not go far enough. The federal rule does not mandate that a physician of the same specialty as the prescribing physician review care denials — a critical feature of New Jersey’s approach. So clinically appropriate care may continue to be inappropriately denied under this rule.
So in the meantime, if you or a loved one have been affected by this perverse process, please consider writing a letter or calling your legislators to bring about change in your state.
As in Washington and New Jersey, when patients and clinicians band together for the betterment of the whole system, we can win. Together, we can create a system that honors the needs of clinicians to make good clinical decisions without roadblocks and of patients to receive high-quality and timely care.
Tina Shah is a pulmonary and critical care doctor at RWJ Barnabas Health in New Jersey and chief clinical officer of Abridge. Devika Bhushan is a pediatrician and public health leader who previously served as California’s acting surgeon general.