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Prior Authorization in Primary Total Hip Arthroplasty: Delays Without Financial Gains
Elizabeth A Abe1, Juan D Lizcano2, Saad Tarabichi3
1Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania.
Insights
Prior authorization (PA) for total hip arthroplasty (THA) does not reduce costs. Patients requiring PA for THA experienced longer wait times for their procedures, indicating it is not a cost-saving measure.
Area of Science:
- Orthopedic Surgery
- Health Services Research
- Health Economics
Background:
- Prior authorization (PA) is used by payers to curb healthcare spending.
- PA may increase administrative burdens and delay patient care.
- The financial impact and cost-effectiveness of PA for total hip arthroplasty (THA) remain unclear.
Purpose of the Study:
- To quantify the financial costs associated with obtaining prior authorization (PA) in patients undergoing primary total hip arthroplasty (THA).
Main Methods:
- A prospective study analyzed 1,788 primary THA patients with commercial insurance (2020-2022).
- Data collected included PA status, service utilization, and claims costs pre-THA and from surgery request to surgery date.
- Matched cohorts compared costs and wait times between patients requiring PA and those who did not.
Main Results:
- No significant difference in mean claims costs was found between patients requiring PA and those who did not, either in the year before THA or from surgery request to surgery.
- Patients requiring PA experienced a statistically significant longer duration from initial surgery request to THA surgery (43 vs. 39 days).
Conclusions:
- Prior authorization (PA) is an ineffective cost-saving strategy for primary total hip arthroplasty (THA).
- PA requirements lead to significantly longer wait times for THA patients, impacting timely access to care.
Background:
Prior authorization (PA) has been implemented by payers to reduce unnecessary health-care utilization. However, obtaining PA has been shown to increase the administrative burden and delay access to care. To our knowledge, financial burden and cost-effectiveness of PA in total hip arthroplasty (THA) are yet to be determined. The purpose of this prospective study was to quantify the costs associated with obtaining PA in primary THA patients.
Methods:
A matched series of 1,788 patients undergoing primary THA with a single, commercial insurance payer from 2020 to 2022 at our institution was included. Data on PA status, number of services utilized, and total claims cost of nonoperative treatment received in the year before THA and incurred from the initial surgery request date to date of surgery were prospectively collected and analyzed.
Results:
When comparing matched cohorts, no difference was found to exist among mean claim costs in the year before THA ($308 ± 220 in PA required versus $316 ± 264 in the no PA cohort, standardized mean difference [SMD) = 0.032) and incurred from initial surgery request date to date of THA ($295 ± 200 in PA required versus $305 ± 249 in the no PA cohort, SMD = 0.041). However, patients who required PA experienced a significantly longer duration from the initial surgery request date to the date of THA (43 ± 39 versus 39 days ±37, SMD = 0.083).
Conclusion:
In the present study, obtaining PA was found to be an ineffective cost-saving measure in patients undergoing primary THA. Additionally, THA patients who required PA experienced significantly longer wait times before undergoing THA.
