In our series on prior authorizations, we have previously considered the administrative burden prior authorizations present for healthcare providers, as well as their potential to delay definitive care for individual patients. Here we examine prior authorizations within the context of health equity.

There is increasing concern and growing evidence that the use of prior authorizations can perpetuate health disparities through disproportionate impact on poor and minority populations.

A “perennial concern” of the American Medical Association (AMA), prior authorizations are more than just a nuisance for providers. In addition to delaying access to treatment—especially new pharmaceuticals and biologics—prior authorizations are associated with higher rates of patient abandonment of treatment plans.

When prior authorization requirements are imposed unequally, their impact on historically marginalized groups can be magnified, further delaying the realization of a fair and equitable healthcare system.

Health equity

Defined by the Centers for Disease Control and Prevention (CDC) as “the state in which everyone has a fair and just opportunity to attain their highest level of health,” health equity is the first pillar of the Centers for Medicare & Medicaid Services’ (CMS’s) strategic plan. It requires recognizing and addressing the impacts of racism, gender oppression, classism, and other forms of institutionalized discrimination on health outcomes.

Many patient advocacy and provider groups see the use of prior authorizations as being in direct opposition to this goal. The American Academy of Family Physicians is among those who contend that prior authorizations “can worsen health disparities and create barriers to care for medically underserved patients, patients of color, LGBTQ+ patients, patients in rural areas, and those at risk for poor health outcomes.”

Provider resources

Prior authorizations require provider time and resources. In a 2022 survey of AMA members, 88% of respondents described the burden associated with prior authorizations as “high” or “very high,” and 35% reported having staff dedicated to working exclusively on securing prior authorizations.

Research shows that dedicated patient navigators working in collaboration with nursing and pharmacy staff can ease the prior authorization process for both providers and patients. But for providers and clinics in rural areas or serving minority populations, adequate staffing is an ongoing challenge. For them, having staff dedicated to the completion of prior authorization paperwork, let alone patient navigators, is an unrealizable ideal.

The Association of Black Cardiologists (ABC) says that lower staffing ratios in the offices of physicians caring for minority and underserved populations with cardiovascular disease (CVD) contributes to treatment disparities. Without ancillary staff to manage prior authorization documentation, submission, and appeals, physicians operating within tight financial margins may not be able to immediately or successfully prescribe the newest or most effective medications.

Patients denied access to clinically indicated therapies for CVD can be at higher risk of hospitalization or a cardiac event. They may also rightly perceive the rejection for first-line care as part of a broader, systemic, and self-perpetuating pattern of discrimination and inequity. This can further distrust of the medical system and erode the patient/provider relationship. The sense of rejection and mistrust may ultimately lead a patient to be less compliant in the use of any second line therapies which they do receive.

Recognizing that the use of prior authorizations can have both immediate medical and long-term systemic impacts, ABC has called for their elimination for guideline directed therapies.

Patterns, obvious and subtle

There are instances in which the overlay of demographic data with patterns of prior authorization use immediately demonstrates the impact of structural racism in the provision of healthcare.

As an example, a 2020 study of the use of prior authorizations for HIV Pre-exposure Prophylaxis (PrEP) in the U.S. found that prior authorizations were most likely to be required for insurance beneficiaries in the South.

That there would be quantifiable differences in the use of prior authorizations by region is immediately problematic. That the South is also the region of the country with the highest annual rate of new HIV infections, the region where the majority of the U.S.’s Black population lives, and the region where Black men are less likely to use PrEP led the study’s lead author to ask if the disparity was by discriminatory design.

Because discrimination in healthcare is frequently unintentional, its manifestations are not always easily recognized. Some patterns of disparity are only identified through the collection and analysis of standardized data. And they may be wholly unexpected.

In one large cohort study on the use of prior authorizations in gynecologic oncology care, researchers were not surprised to identify higher rates of prior authorizations for patients with Medicare Advantage plans.

What the researchers did not anticipate was the extent to which variation of prior authorization requirements aligned with race and, more specifically, with which race. They found that 37% of patients who identified as Asian experienced prior authorization requirements, compared to 20.1% of those who identified as Black, 17.9% of Hispanic patients, and 23.1% of white patients.

Whether this difference was the result of health plan selection, payer distribution, or a higher incidence of rarer cancers was not immediately evident. That the pattern of disparity had not previously been suspected illustrates the insidious nature of discrimination and emphasizes the value of ongoing monitoring of healthcare data.

Stigmatized and high-risk populations

The use of prior authorizations among stigmatized or marginalized populations presents special concerns.

Prior authorization requirements for patients with hepatitis C (HCV) or HIV may include questions about lifestyle choices and behaviors. In some cases, patients may be required to make attestations regarding sexual practices and drug or alcohol avoidance.

For insurance companies, asking if an HCV patient is avoiding alcohol and committed to treatment goals may seem reasonable given that the cost of direct-acting antivirals can run upward of $90,000 for a treatment course. But, for a fearful patient seeking treatment after a period of hesitancy or denial, such questions may seem invasive or accusatory and may discourage continued pursuit of care.

In 2017, the AIDS Foundation Chicago accused UnitedHealth of using prior authorizations for PrEP to discriminate against the LGBTQ community, citing what it characterized as “inappropriate and invasive questioning about (members’) sexual orientation, HIV status and drug use.”

Patients with opioid use disorder (OUD) also experience barriers to treatment. While opioid agonist treatment has been shown to reduce the risk of mortality for patients with OUD, access to drugs such as methadone, buprenorphine, or naltrexone often requires prior authorizations.

For any patient with OUD or other substance use disorder (SUD), the decision to seek or agree to treatment is critical to recovery. And the window of opportunity in which a provider can connect with the patient and initiate treatment may be brief, whether it occurs in the emergency department or in counseling. Delaying the start of treatment until the approval of a prior authorization request can raise the risk of patient alienation, relapse, and death.

Since 2016, at least 20 states and the District of Columbia have passed legislation limiting the use of prior authorizations for SUD medications or services in Medicaid and/or commercial insurance. Restrictions vary widely.  While the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) prohibits health plans from imposing more restrictive limitations on mental health and SUD benefits than on medical benefits, it does not guarantee that either category of benefits is equally accessible. In a joint report to Congress last year, the Department of Labor, the Department of Health and Human Services, and the Treasury raised questions about plans’ compliance with the MHPAEA. And  the Medicaid and CHIP Payment and Access Commission (MACPAC) found that MHPAEA had not improved access to behavioral health services including SUD treatment and that accessing parity was particularly complicated.

Patient understanding

While most of the administrative burden associated with prior authorizations falls on providers, patients are frequently required to provide supporting documentation or other information. This can present challenges for patients with cognitive impairments or limited literacy, as well as for patients for whom English is not their preferred language—all groups associated with lower socioeconomic standing.

Poor Americans are less likely than their wealthier peers to engage with the healthcare system in general. They are also more likely to characterize the completion of healthcare related administrative tasks, including the provision of prior authorization documentation, as burdensome.

Paperwork, which might be a tedious but manageable annoyance for a middle-class college graduate in a suburban environment, can become an insurmountable obstacle for a patient with a learning disability or a rural resident without access to reliable internet access. And when a patient is asked to sign a form which they cannot read or do not fully understand, they are deprived of the opportunity to provide informed consent.

Conclusion

For health insurance plans, prior authorizations can be an effective means of controlling healthcare spending and assuring that medications and treatments are properly prescribed. But evidence suggests that, as currently employed, they perpetuate existing inequalities in the healthcare system and act as barriers to health equity. A comprehensive reassessment of the authorization process, coupled with collaborative efforts from stakeholders, can pave the way for a more just and inclusive healthcare system that prioritizes equitable access to quality care for everyone, regardless of their socioeconomic status, race, or ethnicity.