The U.S. health care landscape is undergoing historic change—from Medicare drug price negotiations to rising public scrutiny of insurance practices. As policymakers have increasingly focused on addressing administrative waste, prior authorization has become a top priority.
In June, several private insurers pledged to address the issue of prior authorization. They promised to reduce the number of treatments requiring authorization, standardize electronic submissions, ensure continuity of care during insurance transitions, and expand real-time approvals by 2027. They also proposed dashboards to enhance transparency and improve communication among insurers, providers, and patients. While these goals are promising, the pledge lacks the force of policy or law. It has no enforcement mechanism. It represents a handshake, not a mandate.
Prior authorization, however, transcends mere administrative inconvenience; it poses a clinical risk. It delays treatment, contributes to physician burnout, and erodes trust in a system already under strain.
Prior authorization transcends mere administrative inconvenience; it poses a clinical risk. It delays treatment, contributes to physician burnout, and erodes trust in a system already under strain.
The burden is staggering. On average, physicians complete 43 prior authorizations per week, dedicating over 16 hours filling out forms, waiting on hold, and appealing denials. These hours do not come from spare time; they detract from patient care. The delays are not just inefficient; they’re dangerous. We have seen a child with new-onset Type 1 diabetes stuck in the hospital while waiting for the approval of generic insulin. A critically ill infant in respiratory distress was denied admission because a non-indicated medication had not been administered. A patient with severe anxiety was denied short-term disability because no labs existed to “prove” the condition. Nearly 80 percent of physicians report that prior authorization has led patients to abandon necessary care. These examples are not anomalies; they reflect a daily reality.
The prior authorization process itself feels outdated, relying on faxed forms and peer-to-peer phone calls between highly trained specialists and insurance employees who may lack relevant clinical expertise but whose judgments override those of the physician. If the call is missed or the fax does not go through, the request is denied. The patient must then wait, pay out of pocket, or give up.
While Medicare and many state Medicaid programs minimize the use of prior authorization, private insurers often impose the most aggressive and opaque barriers. Their financial incentives are clear: collect as many premiums, copays, and deductibles as possible while restricting access to care—regardless of necessity. The underlying assumption is that if physicians or patients want a service badly enough, they will spend their time fighting for it.
Every delay increases costs, not only for the patient but for the entire system. Deferred care leads to worse outcomes and more expensive interventions down the line. Every hour spent battling with insurers is an hour not spent diagnosing, operating, or counseling.
The American public is losing faith in this system. Patient satisfaction has plunged to its lowest point in nearly 25 years and physician burnout is at record highs. Health care spending has more than doubled over the last decade, totaling nearly $5 trillion in 2023. Yet, our health outcomes remain mediocre. Life expectancy lags behind that of peer nations, and infant (PDF) mortality rates vary drastically by state. The results do not align with the costs.
Every delay increases costs, not only for the patient but for the entire system. Deferred care leads to worse outcomes and more expensive interventions down the line.
Although the recent pledge outlines a positive direction, direction alone is insufficient. We need action. Voluntary improvements cannot substitute for enforceable standards. Just as the Affordable Care Act mandated coverage for essential benefits, we need federal mandates to restrict prior authorization for evidence-based care across all payors.
When approval delays put a child’s life at risk or deny someone access to basic medications, the real cost is human. If you have never experienced prior authorization, take a closer look: the prescription that was unavailable at the pharmacy; the postponed procedure; the therapy that went uncovered. It is everywhere, and it is time to fix it.
America does not need more paperwork; it needs more care. True health care system transformation begins with placing physicians and patients—not insurers—back at the center of the system.
– Jihad Abdelgadir is a neurosurgeon and health policy researcher at the University of Utah. Gabriela Plasencia is a board-certified family physician and associate physician policy researcher at RAND. Published courtesy of RAND.
