Preamble: The previous blog looked at 2026 health plan comparative metrics for all lines of business and national health plans that can be used to support NCQA’s new UM 1 requirements. This blog examines both the value of having that process in place and the potential unintended consequences.

Prior authorization (PA) has long been used by health plans as a utilization management strategy to help ensure that services are medically necessary, clinically appropriate and consistent with coverage requirements. Used appropriately, prior authorization can support responsible stewardship of healthcare resources and help control unnecessary spending.

But prior authorization does not operate in a vacuum.

Every authorization requirement creates an intervention between a clinician's recommendation and the patient's receipt of care. When that intervention is well targeted, efficient and evidence based, it may contribute to appropriate utilization. When it produces unnecessary delays, administrative complexity or barriers to evidence-based treatment, however, the downstream consequences can affect patients, providers—and ultimately the health plans attempting to manage healthcare costs.

A systematic review published in The American Journal of Medicine provides important evidence about those consequences.

Moving Beyond Perceptions to Patient Outcomes

Concerns about prior authorization have often been documented through physician surveys. The systematic review, led by Johns Hopkins researchers, went further by examining published research evaluating the relationship between prior authorization and actual patient care and outcomes.

The researchers reviewed 25 studies across multiple clinical areas, including oncology, cardiology, behavioral health, pediatrics, rheumatology and infectious diseases. The findings associated prior authorization requirements with care delays and treatment gaps as well as disease exacerbation, preventable hospitalization, prolonged hospital stays and lower rates of disease-free survival.

The evidence is not without limitations. Twenty-two of the 25 studies were retrospective, and the studies differed considerably in their populations, clinical specialties and outcome measures. The authors appropriately caution that the existing literature cannot fully quantify the breadth or magnitude of harm associated with PA.

Nevertheless, the consistency of findings across multiple clinical areas deserves attention.

A Delay Is Not Always Administratively Neutral

One of the most important lessons from the research is that the consequences of a prior authorization decision may extend far beyond the authorization transaction itself.

For example, among patients with inflammatory bowel disease, insurer-mandated prior authorization for biologic therapy was associated with treatment delays and increased healthcare utilization. Patients with severe asthma experienced substantial delays in receiving prescribed biologics; some experienced exacerbations requiring steroids and hospitalization while waiting for treatment.

The effects extended to other clinical conditions. Among patients with atrial fibrillation, restrictions on oral anticoagulants were associated with increased risks of serious complications. In another study involving outpatient parenteral antimicrobial therapy, patients experiencing PA delays remained hospitalized longer—even though their total duration of antibiotic therapy was similar.

These findings raise an important question for utilization management programs:

Did the authorization requirement reduce total healthcare costs—or simply shift costs somewhere else?

A medication, procedure or treatment delayed today may potentially result in another office visit, additional medication, an emergency department visit or hospitalization tomorrow.

That distinction matters when evaluating the true effectiveness of prior authorization.

The Patient Experience Can Become a Clinical Issue

For patients, prior authorization is often experienced not as a utilization management strategy but as waiting.

Recent physician survey data reinforce the magnitude of that concern. In the 2026 AMA survey, 95% of physicians reported that prior authorization delays access to necessary care, 92% reported a negative effect on clinical outcomes and 79% reported that patients sometimes abandon treatment because of authorization challenges. Physicians also reported that PA can contribute to urgent or emergency care and hospitalization.

The systematic review gives these physician observations additional significance because published studies demonstrate measurable associations between PA-related delays and adverse clinical outcomes.

This is particularly concerning when the patient's condition is time sensitive.

In oncology, for example, the review identified treatment delays involving radiation therapy and other cancer treatments. For patients with brain metastases, longer intervals between imaging and stereotactic radiation treatment were associated with substantially lower rates of local disease control. Other oncology studies documented delays associated with authorization and appeal requirements.

For patients already dealing with the uncertainty of cancer, behavioral health conditions, serious inflammatory disease or cardiovascular disease, the authorization process can therefore become more than an administrative inconvenience. Timeliness itself can be a component of quality.

Providers Bear a Significant Administrative Cost

Prior authorization also consumes substantial provider resources.

Physician surveys have consistently documented large PA workloads. The systematic review cited 2024 AMA data showing that physicians and their staffs completed an average of 39 prior authorizations each week, requiring approximately 13 hours of physician and staff time. Eighty-nine percent reported that PA increased burnout.

More recent AMA data continue to show substantial burden. Physicians reported approximately 40 PA requests per physician each week and about 13 hours of physician and staff time devoted to the process. Forty percent reported employing staff dedicated exclusively to prior authorization.

That represents a real healthcare cost.

Every hour spent determining requirements, submitting documentation, responding to requests for additional information, conducting peer-to-peer reviews and appealing denials is an hour that cannot be spent on another healthcare activity.

Providers absorb much of that expense, but the healthcare system ultimately bears it.

Health Plans Bear Administrative Costs, Too

The administrative burden is not one-sided.

Health plans must maintain the infrastructure necessary to receive authorization requests, apply criteria, perform clinical reviews, communicate determinations, conduct peer-to-peer discussions, process appeals, oversee delegated functions, monitor timeliness and analyze utilization.

The systematic review cites an estimated 270 million prior authorization requests in 2024. It also notes that only 35% of medical plans had adopted a fully electronic approach to PA submissions. The authors point to lack of uniformity among health plan requirements as an obstacle to further automation.

Consequently, inefficient PA processes can generate administrative costs on both sides of the transaction.

That creates an important opportunity for health plans: determining where prior authorization genuinely adds clinical and financial value and where the administrative expense and downstream consequences may outweigh the savings.

The Right Question Is Not Whether Prior Authorization Is Good or Bad

The healthcare system needs mechanisms to promote appropriate utilization and control unnecessary costs. Eliminating oversight altogether is not the answer.

But neither is assuming that every authorization requirement saves money simply because it prevents or delays an expenditure.

The better question is:

Where does prior authorization provide sufficient clinical and financial value to justify the burden it creates?

That requires examining the entire episode of care.

Consider a hypothetical authorization that prevents or delays a $5,000 treatment. Measuring only the immediate authorization outcome could suggest savings. But if the patient subsequently requires additional physician visits, alternative therapies, an emergency department visit or hospitalization, the total cost of care may actually increase.

The systematic review found precisely this type of downstream utilization across several conditions. Patients experiencing PA delays and restrictions experienced exacerbations, emergency department utilization, hospitalization and other complications.

In the 2026 AMA survey, 88% of physicians similarly reported that prior authorization leads to greater overall healthcare resource utilization.

This suggests that utilization management effectiveness should not be measured solely by what was denied or avoided. It should also consider what happened to the patient afterward.

Prior Authorization Should Be Targeted, Evidence Based and Measurable

The goal should be judicious use of prior authorization—not simply more PA or less PA.

Health plans should continually evaluate whether authorization requirements remain appropriate based on clinical evidence, utilization patterns, approval and denial rates, appeal and overturn patterns, administrative burden, patient risk and downstream utilization.

Several principles emerge from the evidence:

• Apply prior authorization where there is meaningful opportunity to address inappropriate, unsafe or unnecessarily costly utilization rather than applying it broadly to services with consistently high approval rates.
• Align medical necessity criteria with current evidence-based clinical practice guidelines whenever possible.
• Examine authorization turnaround times in relation to the clinical urgency of the service—not simply whether regulatory or accreditation time frames were technically met.
• Analyze denial and appeal patterns to identify requirements that may be creating work without producing meaningful utilization-management value.
• Automate routine and predictable approvals wherever appropriate.
• Evaluate the effect of PA on treatment abandonment, alternative treatment use, emergency department visits, hospitalization and other downstream utilization.
• Assess administrative burden for both providers and the health plan as part of the true cost of the PA program.
• Stratify findings where appropriate to identify whether authorization policies disproportionately affect particular populations or clinical conditions.

From Transactional Metrics to Outcomes

Perhaps the most important recommendation from the systematic review is the call for longitudinal measurement.

The researchers propose that health plans use claims data to compare outcomes for patients whose requested services are approved with those whose services are denied or delayed. They argue that plans already possess much of the longitudinal data necessary to begin examining these relationships.

That represents an important evolution in thinking about utilization management.

Traditional PA measurement tends to focus heavily on the transaction: Was the request processed? Was the decision timely? Was the correct notification sent? Was the appropriate clinical reviewer involved?

Those measures remain important.

But they do not answer the larger question:

What happened to the patient because of the utilization management decision?

Health plans increasingly have the analytical capability to ask that question.

Did the patient receive the recommended treatment?

Was treatment delayed?

Was an alternative therapy required first?

Did the patient abandon treatment?

Was there an emergency department visit or hospitalization afterward?

What was the patient's total cost of care?

And ultimately, did the utilization management decision contribute to a better—or worse—clinical and financial outcome?

Finding the Appropriate Balance

Prior authorization exists for legitimate reasons. Healthcare resources are finite, inappropriate utilization occurs, treatment costs continue to rise, and health plans have a responsibility to manage resources responsibly.

But stewardship requires looking at all of the costs.

A PA requirement that prevents unnecessary care can create value.

A PA requirement that delays necessary evidence-based care, requires hours of provider and health plan administrative work, and ultimately contributes to an emergency department visit or hospitalization may accomplish the opposite.

The Johns Hopkins-led systematic review does not establish that every prior authorization requirement causes harm, nor does it quantify the full impact of PA across the healthcare system. Its authors acknowledge the limitations of the available evidence. What it does demonstrate is that measurable adverse outcomes have been identified across multiple clinical areas and that more rigorous longitudinal measurement is needed.

That should move the conversation beyond the question of whether prior authorization should exist.

The more productive question is whether each prior authorization requirement is producing enough value to justify its clinical, administrative and financial consequences.

For health plans committed to quality, affordability and member-centered care, the objective should be clear:

Use prior authorization where it adds value. Make it as efficient as possible where it is necessary. Remove unnecessary barriers where it does not. And measure not only the immediate utilization decision, but what happens to the patient afterward.

That is how prior authorization can function as a true healthcare value strategy rather than simply a cost-control mechanism.

As health plans implement NCQA's enhanced UM 1 requirements and comparative metric reviews, consider whether your measures are capturing the true effectiveness of prior authorization. Compliance is important, but meaningful improvement comes from understanding how utilization management decisions affect members, providers and the total cost of care.

References

Murphy J, Beauchamp N, Sun KJ, et al. Systematic review of the effects of prior authorization on patient outcomes. The American Journal of Medicine. DOI: 10.1016/j.amjmed.2025.08.018. Published online September 3, 2025.
The American Journal of Medicine — Full Article

Johns Hopkins Medicine. “Researchers Find Measurable Patient Harm Linked to Prior Authorization.” Clinical Connection, Fall 2025.
Johns Hopkins Medicine — Clinical Connection

American Medical Association. Prior Authorization Physician Survey, May 13, 2026.
AMA Prior Authorization Physician Survey

American Hospital Association. “AMA survey shows physicians, patients continue to be heavily burdened by prior authorization.” May 14, 2026.
American Hospital Association summary of 2026 survey findings.

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