In December 2024, UnitedHealthcare CEO Brian Thompson was assassinated in New York City. Investigators recovered shell casings at the scene inscribed with the words “Delay, Deny, Depose.” The phrase was a direct criticism of the healthcare industry and a specific patient handling practice used by almost all American health insurance companies—prior authorization. Prior authorization (PA) is a cost-control plan in the medical field that requires all doctors to obtain approval from insurers before administering certain services or medications to patients. PA policies are practiced to ensure that a treatment or service is medically necessary for a patient. However, both patients and providers in the medical field have deemed them to be an expanding threat. In a 2023 study done by the American Medical Association (AMA), the vast majority of licensed physicians surveyed agreed that prior authorization policies lead to a delay in nearly all cases of necessary patient care. Jacob Castiglia, MD, claims that rather than focusing on ensuring patient wellbeing, PA policies prioritize cutting costs and making the most profit. In an industry that ideally should be focused on human care, what are the effects of this “denial for dollars” (T. Christian Miller) business on both patients and providers in the medical field?
One of the major problems with prior authorization (PA) is that it is more centered on acquiring profits than effectively treating patients. EviCore, a third party company hired by many healthcare giants to handle prior authorization requests, claims that they objectively analyze all PA requests in order to ensure that they are necessary and cost-effective. Through this analysis EviCore directs providers away from delivering inappropriate and unsafe care, while also preventing patient abuse or misuse of a treatment. EviCore states that their first priority is to improve the quality and safety of healthcare, and decreasing unnecessary costs as a result is nothing more than a “happy coincidence.” However, medical professionals who work with EviCore and similar companies believe this coincidence is actually a cost-cutting strategy used to generate more profit. Barbara McAneny, former president of the American Medical Association (AMA), claims that EviCore and companies like it approve prior authorizations “based on the decision that is more profitable for them.” McAneny’s argument is supported by the fact that EviCore markets itself to companies by promising a 3-1 return on investment—meaning, for every $1 dollar companies spend on EviCore, $3 will be cut from medical care and other costs (Evernorth). Rather than focusing on the quality and safety of healthcare, EviCore appears to be chiefly concerned with fulfilling their financial promises to health insurance businesses.
Another prominent issue with the prior authorization system is its inefficiency. Jacob Castiglia, a respected researcher in the medical research field, describes how in obtaining prior authorization, patients are often faced with complicated paperwork, long zoom meetings, and other difficult processes. Castiglia believes that these inefficiencies are no coincidence, rather they are a form of “weaponized bureaucracy” used by health insurance companies to deter patients from seeking medical care. Not only do these delays prevent patients from receiving care, but they also lead to fatalities. In an interview, Dr. Cheryl Kunis, a licensed nephrologist in New York City, recalled the story of one of her patients who became a victim of the PA system. The patient that Dr. Kunis was treating needed a PET scan to check for cancer. The surgeon who would potentially operate on the patient said that he would only perform surgery once the PET results returned and he had more information. The request was initially denied, and Dr. Kunis sent in many appeals in order to overturn the decision. Six months later the appeal was finally approved, but by that time the patient was already dead.
In addition, the burden of PA takes away significant chunks of time from physicians, forcing them to spend more time on menial tasks rather than caring for patients. The AMA reports that prior authorization requirements for a single doctor take up 12 hours of physician and staff time each week. This plague of inefficiency has also impacted the medical system as a whole. 87% of physicians reported that prior authorization requirements led to a utilization of health care resources at an overall higher rate. Instead of helping patients and further advancing the medical system, these resources are being wasted on additional office visits, peer-to-peer review meetings, and hospitalizations that result from PA delays.
Prior authorization is a corrupt system where decisions are made to save the most costs rather than serving patients best. Human lives become numbers in a computer, and a patient’s decision between life or death is chosen by standard operating procedures. This attitude of operation detaches health insurance companies from the reality of their actions. Since the human element is removed from their work, health insurance companies disregard the consequences (patient harm and death) of their endeavors (denial of patient care). Moreover, what makes prior authorization worse is the fact that it is integrated deeply into the efficiency of the PA system, making it very easy for the bureaucratic focus on cost-control to supersede the human duty to provide care.
Prior authorization is a corrupt, inefficient system that promotes more harm than good in our medical system. Insurers working within PA believe that cutting the high, yet critical cost of certain medical care is the best path towards raising profits, however, they are unaware and unsympathetic to the irrevocable harm they are causing for patients and the American medical system. Family physicians serve as the leaders behind the fight for PA reform. Local doctors have partnered with the American Medical Association to create grassroots campaign resources where you can share your personal experiences with PA and connect with others to take action. For it is when we turn a blind eye to the bureaucratic injustice of PA that we allow the greed of health insurers to triumph over the needs of the American public.
