Adverse Effects of Health Plan Prior Authorization on Clinical Effectiveness and Patient Outcomes: A Systematic Review.

Abstract

Prior authorization requirements by health insurance plans have become a barrier to healthcare delivery in the United States in terms of clinical efficiency, patient and provider experience. Surveyed physicians report associations with care delays, reduced clinical effectiveness and compromised patient outcomes. In this systematic review, we synthesized the published evidence regarding harmful effects of prior authorization on disease management and patient outcomes. Twenty-five studies were included. In addition to care delays, authorization requirements were associated with disease exacerbation, preventable hospitalization, prolonged hospital stay, and lower rates of disease-free survival. Studies spanned multiple specialties including oncology, cardiology, behavioral health and pediatrics. Published evidence shows that prior authorization requirements are associated with measurable patient harm across multiple healthcare domains. Recognizing that a small number of retrospective studies do not adequately quantify the harm, we propose establishing national quality metrics for health plans, using claims data to track longitudinal outcomes in patients subject to delays and denials.