FROM DELAYS TO DETERIORATION: A REVIEW OF THE IMPACT OF PRIOR AUTHORIZATION ON PATIENT HEALTH
Author(s)
Lucia Perez-Kempner, MSc1, Harshil Patel, BS2, Sangeeta Budhia, BSc, MSc, PhD2.
1Senior Consultant, Parexel International, Lebrija, Spain, 2Parexel International, London, United Kingdom.
1Senior Consultant, Parexel International, Lebrija, Spain, 2Parexel International, London, United Kingdom.
OBJECTIVES: The need to rationalize drug expenditure has driven the use of prior authorization (PA) by US insurers, where insurers must approve the drug use before granting coverage. With growing pressure in the US to reduce drug spending, this study explores the burden of PA on patients and examines how expanding PA requirements may affect access to care and overall health outcomes.
METHODS: A systematic review was conducted in PubMed, searching open-access studies published in the last 5 years on PA. Studies reporting on the burden of PA on patients were selected. No disease or population exclusion criteria were applied.
RESULTS: The review identified 77 studies, of which 18 were selected. Among these, 11 reported disease-specific data, and seven were disease-agnostic. All studies identified PA as a barrier to optimal healthcare, with six studies relating PA to negative health outcomes. The primary barriers to care associated with PA were treatment denials, delays in initiating treatment, and selection of suboptimal treatments. PA was particularly associated with treatment initiation delays ranging from one to 31 days. For cancer patients seeking pain therapy, these delays often resulted in unnecessary suffering. The impact extended beyond physical health, as one study reported increased anxiety among patients facing PA-related barriers. Overall, the evidence consistently linked PA to detrimental health outcomes, contributing to avoidable negative experiences and patient distress.
CONCLUSIONS: This review underscores the critical need for evidence-based policy reforms that harmonize cost-management goals with patient access and care quality, while also measuring the economic consequences of PA-related health outcomes. Despite PA’s intended purpose to optimize spending, its application frequently causes treatment delays, denials, and inferior therapy selection, resulting in preventable harm and heightened patient distress. Interpretation of these findings should account for potential selection bias.
METHODS: A systematic review was conducted in PubMed, searching open-access studies published in the last 5 years on PA. Studies reporting on the burden of PA on patients were selected. No disease or population exclusion criteria were applied.
RESULTS: The review identified 77 studies, of which 18 were selected. Among these, 11 reported disease-specific data, and seven were disease-agnostic. All studies identified PA as a barrier to optimal healthcare, with six studies relating PA to negative health outcomes. The primary barriers to care associated with PA were treatment denials, delays in initiating treatment, and selection of suboptimal treatments. PA was particularly associated with treatment initiation delays ranging from one to 31 days. For cancer patients seeking pain therapy, these delays often resulted in unnecessary suffering. The impact extended beyond physical health, as one study reported increased anxiety among patients facing PA-related barriers. Overall, the evidence consistently linked PA to detrimental health outcomes, contributing to avoidable negative experiences and patient distress.
CONCLUSIONS: This review underscores the critical need for evidence-based policy reforms that harmonize cost-management goals with patient access and care quality, while also measuring the economic consequences of PA-related health outcomes. Despite PA’s intended purpose to optimize spending, its application frequently causes treatment delays, denials, and inferior therapy selection, resulting in preventable harm and heightened patient distress. Interpretation of these findings should account for potential selection bias.
Conference/Value in Health Info
2026-05, ISPOR 2026, Philadelphia, PA, USA
Value in Health, Volume 29, Issue S6
Code
PCR76
Topic
Patient-Centered Research
Disease
No Additional Disease & Conditions/Specialized Treatment Areas