Influence of prior authorization requirements on provider clinical decision-making

Area of Science:

• Health Services Research
• Medical Economics
• Clinical Practice

Background:

• Prior authorization (PA) is intended to ensure safe and cost-effective medication use.
• However, the administrative tasks associated with PA can impose significant burdens on healthcare providers.
• This burden may influence clinical decision-making and patient care.

Purpose of the Study:

• To examine the impact of prior authorization (PA) administrative tasks on healthcare providers' treatment decisions.
• To identify factors contributing to the burden of PA, including health plan requirements and insurer communication.

Main Methods:

• A cross-sectional online survey was administered to US medical providers in 2020.
• Multivariate path analysis assessed associations between practice characteristics, PA burden, and prescribing behaviors.
• Weighted analyses addressed potential nonresponse bias.

Main Results:

• Step therapy requirements significantly influenced clinical decision-making.
• Perceived likelihood of PA, communication issues with insurers, and health plan requirements also affected decisions.
• Respondents indicated altering clinical decisions to circumvent PA requirements.

Conclusions:

• Healthcare providers may modify treatment plans to avoid prior authorization (PA) burdens, even when the PA medication is clinically indicated.
• Improving PA processes through enhanced communication, transparency, and standardized documentation is crucial.
• Streamlined PA can better align with goals of safe and effective medication use.