Burden with No Benefit: Prior Authorization in Congenital Cardiology

Area of Science:

• Cardiology
• Health Policy
• Healthcare Administration

Background:

• Prior authorization is a health insurance process to approve medical services.
• It is frequently used in adult congenital and pediatric cardiology (ACPC) due to complex patient needs.
• The process often leads to administrative burdens and patient care delays.

Purpose of the Study:

• To highlight the administrative and clinical burdens of prior authorization in ACPC.
• To advocate for the elimination of prior authorization for ACPC patients.
• To discuss the impact of prior authorization on care inequities.

Main Methods:

• Literature review and analysis of prior authorization processes in ACPC.
• Examination of administrative burdens on clinical care teams.
• Assessment of delays in patient care and impact on vulnerable populations.

Main Results:

• Prior authorizations are rarely denied in ACPC but impose significant administrative workload.
• The process causes delays in accessing necessary diagnostics, procedures, and medications.
• Prior authorization exacerbates existing care inequities, disproportionately affecting women, minorities, and low-income groups.

Conclusions:

• Prior authorization imposes undue burdens on routine and complex care in ACPC.
• The process contributes to care delays and worsens health inequities.
• Eliminating prior authorization for ACPC patients is recommended to improve patient care and reduce administrative strain.