Have you ever left a doctor's appointment with a whole plan to tackle some health issue you're facing, only to get a call later saying someone at your insurance company who may or may not be a doctor needs more information before they'll approve coverage for this thing your doctor is certain you need.?

That is the dreaded prior authorization, and it's the topic of this week's Healthcare Triage. On paper, prior authorization might sound kind of logical.

The official stories that insurers want to make sure treatments are medically necessary, cost effective, and appropriate. Unfortunately for patients, it feels more like an obstacle course with a finish line that keeps moving further away. First, there's the waiting.

Prior authorization involves paperwork, review processes, and usually some back and forth between your provider and your insurer This can delay care by days or even weeks, which is a big deal for many health issues. Patients don't usually receive a heads up that prior authorization is going to be required. They just find out when something doesn't go through, which means patients are having to react instead of plan.

That's unfortunate, because being able to plan is really helpful in complicated situations, and prior authorizations can absolutely get complicated To begin, the criteria are not standardized. They vary by insurer, insurance plan, medication procedure, and more. That means even doctors who deal with this all the time can't always predict what will be required From the patient perspective, it feels arbitrary.

One day something's covered, the next day it's not. And the explanation is buried in documentation that might as well be written in another language. So what do patients do?

They become coordinators. They tag team between the doctor's office and the insurance company. They sit on hold explaining the situation to different people who can't see what the last person documented.

And of course, not everyone can do all that. Not everyone can take time off work to sit on the phone. Not everyone feels comfortable pushing back or escalating an issue.

In most cases, treatments are much more likely to just fall by the wayside. Administrative hurdles, like prior authorization, can lead to patients abandoning treatment altogether, and even when patients stick with it, the outcome can still be messy Denials are common. There's an appeals process for that.

But you guessed it that takes a bunch more work. It requires more documentation, more time, and more clinical justification from your provider. The good news is that when appeals are actually completed, a significant portion of denials get overturned.

The bad news is that a lot of people just don't have the time, will, or know how to do them. the patient's perspective, it kind of feels like the system is set up to say no first, maybe later, but only if you're willing and able to work hard enough and willing to accept that while you're working, you're going to feel pretty frustrated. this is even more than frustration, delays, and care associated with worse health outcomes. Sometimes, care's time sensitive and administrative issues can prolong the time it takes to access needed procedures and medications. It can also impact a patient's adherence to taking medication or scheduling appointments.

If getting care becomes a multi-step process with uncertain outcomes, people are less likely to follow through consistently on the provider side. Clinicians might steer their patients towards treatments that are easier to approve, even if they aren't the most preferred or appropriate for the situation, not because they don't care, but because they're trying to get patients treatment sooner rather than later. So what do we do about it?

The research points to a few potential solutions, one being standardization, basically making prior authorization requirements more consistent across insurers so patients and providers aren't constantly guessing what's needed. Another is expanding electronic prior authorization systems, which can reduce delays by integrating requests directly into clinical workflows. Instead of relying on faxes and phone calls that feel like they belong in the late 90s.

There's also growing discussion around gold carding, where providers with the track record of appropriate prescribing face fewer authorization requirements and policy efforts aimed at increasing transparency so patients actually know upfront when a treatment might be delayed or denied. These changes can reduce some of the friction, but they don't eliminate the fundamental tension of trying to control costs while also ensuring timely, patient centered care. But right now, patients are absorbing most of the consequences of that tension, and they could use some relief.

Academy health is all about making research matter, turning evidence into real world impact on health and health care. That's exactly what healthcare triage is about to breaking down the complex, sometimes messy health policy and research stories that affect all of us. Basically, we're tired of the nonsense, and that's why we've teamed up to bring you this important series.

Let's fight the nonsense together. Check out some of the other video series we've made with Academy Health, including this one on getting the right care. We also appreciate it if you'd like this video and subscribe to the channel.

Maybe go on over to Patreon.com Healthcare Triage where you personally can help support the show. Make it bigger and better. We'd especially like to thank our research associates, Edward Liljeholm and Christopher Learn and of course our Surgeon Admiral Sam.