Prior Authorization: A Hidden Influence on Provider Behavior

For many patients, getting a prescription for a new medication often involves an extra step for their doctor: prior authorization (PA). This process, required by insurance companies, is intended to ensure safety and quality control. However, it can also create significant delays, contributing to provider frustration and, in some cases, negatively impacting patient care.

Dr. Stephen Salzbrenner, an Assistant Professor of Psychiatry at the University of Nebraska Medical Center, and his team recently published a study in the Journal of Medical Internet Research that delves into this very issue. Their paper, "Prior Authorization of Medication and Its Influence on Provider Behavior: Latent Class Analysis," explores providers’ experiences with PA and investigates how PA affects clinical decision-making.

Identifying Patterns in a Complex System

The team’s study, a nationwide survey of over 1,100 prescribers used a sophisticated statistical method called latent class analysis. This allowed them to identify four distinct subgroups of providers based on their experiences with and behaviors related to prior authorization. These groups shared characteristics such as:

• Experience with PA denials: Some providers had PA requests denied more frequently by insurance companies.
• Communication issues: Some providers experienced more challenges communicating with insurance companies about PAs.
• Age, specialty, and patient load: Providers’ age, speciality, and the number of patients on their caseload directly influenced their approach to prior authorization.

The research also found that providers who reported the most "problematic" PA experiences were significantly more likely to make specific kinds of clinical decisions. These included changing a patient's diagnosis to meet PA criteria, avoiding newer medications altogether due to anticipated delays, and prescribing alternative medications when PA is delayed.

The Human Cost of Paperwork

The study’s findings reveal that negative experiences with PA can influence providers’ behaviors in potentially concerning ways. Some providers, particularly psychiatrists, younger clinicians, or those with a higher patient load, are more likely to alter their clinical decisions in response to PA-related challenges, such as delays, denials, or excessive paperwork. 

This has important implications for insurance companies, as it highlights that a "one-size-fits-all" approach to PA may not be effective. Recognizing and addressing the distinct needs of different provider subgroups could help reduce the risk of clinical decisions that may negatively affect patient care or public health. For example, streamlining or tailoring the PA process for specific specialties or high-volume practices could help ensure patients receive the most appropriate and timely care.

Dr. Salzbrenner and his team chose to publish their work in the Journal of Medical Internet Research due to its topical fit and high impact rating. The journal’s reputation as a leader in medical informatics and digital health makes it the ideal platform to share this critical research, which has implications for how insurance companies, providers, and patients interact within the healthcare system.

Interested in a deeper look at how prior authorization affects provider behavior? Watch the video to hear directly from Dr. Stephen Salzbrenner, and read the full research article to explore the detailed findings and their implications.

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