A recent study led by Johns Hopkins researchers reviewed evidence across 25 U.S. studies and found that health plan prior authorization requirements are associated with delays in care, disease exacerbations, preventable hospitalizations, prolonged inpatient stays and lower rates of disease-free survival in cancer care.

The findings, published Sept. 3 in The American Journal of Medicine, drew from diverse specialties: oncology, cardiology, behavioral health, pediatrics, rheumatology and infectious diseases. Examined together, the review indicates that delays caused by prior authorization requirements result in harm across populations and health plans.

“When you increase the interval for a patient to start the treatment they need, certain conditions worsen, sometimes to the point of emergency room visits or hospitalization,” says senior author Pamela Johnson, professor of radiology and radiological science at the Johns Hopkins University School of Medicine and vice president of care transformation at the Johns Hopkins Health System. “That’s not abstract. That’s potentially life-threatening disease exacerbation in real people, including children.”

The review looked at studies on treatments for asthma and inflammatory bowel disease, biologic therapies for autoimmune disease, psychiatric and substance use medications, anticoagulants for atrial fibrillation, outpatient antibiotics, and cancer treatments.

“It’s a black box when a health plan decides what can or can’t happen,” says co-author Brandyn D. Lau, associate professor of radiology and radiological science at the Johns Hopkins University School of Medicine and associate faculty at the Armstrong Institute for Patient Safety and Quality. “Providers see the consequences at the bedside, but the decision-making upstream is hard to observe and even harder to measure. This review begins to open that box.”

The review found that restricted access to anticoagulants left atrial fibrillation patients at higher risk of stroke or bleeding, while delays in outpatient antibiotic approvals prolonged hospital stays, raising costs and exposing patients to additional risks.

In behavioral health, 11 studies linked prior authorization to treatment interruptions, higher relapse rates and worse outcomes for patients with psychiatric illness or substance use disorder. Removing restrictions increased treatment starts, reduced relapse and lowered emergency visits, the review found.

“The stated intent of prior authorization is standardization and safety,” says Lau. “But the execution has created different standards of care based on health plan and patient, introducing disparities that we would not tolerate in other industries.”

In oncology, even delays of one to three weeks in starting guideline-based treatments correlates with worse control of disease and lower survival. Patients frequently encountered high denial rates for advanced therapies such as proton beam radiation, despite alignment with national practice guidelines.

“Patients with cancer are already subject to financial toxicity and intense uncertainty,” Johnson says. “Adding approval uncertainty and treatment delays is particularly harmful, especially when medical decision-making aligns with National Comprehensive Cancer Network guidelines.”

The review also highlighted systemwide costs detailed in American Medical Association physician surveys. Respondents reported spending an average of 13 hours a week on prior authorizations, completing nearly 40 requests. Almost all participants say prior authorization requirements delay necessary care, with some patients abandoning treatment entirely. Nearly one-third have seen serious adverse events linked to these delays, including hospitalization or permanent harm.

“We are held accountable by the Centers for Medicare & Medicaid Services and health plans for quality and efficiency,” Johnson says. “But no one is measuring health plans’ performance. When patients appeal, denials are overturned most of the time, which raises questions about whether many denials should have happened at all.”

Researchers note that most of the included studies were retrospective and relatively small, but the consistency of harm across conditions suggests broader impact.

“We have a massive lack of data about real-world outcomes when patients are subject to prior authorization delays and denials,” Johnson says. “But in that deficiency, we see an opportunity. Health plans already hold longitudinal claims data that could be analyzed to evaluate outcomes when evidence-based care is delivered. There just needs to be a willingness to use it.”

Through the support of a Bloomberg Nexus grant, the Johns Hopkins University School of Medicine team is convening representatives of health systems, health plans, policymakers and quality organizations to align measures, leverage claims data at scale, and begin harmonizing prior authorization rules for common conditions. Titled Transforming Measures to Drive Quality Outcomes and Reduce Costs: Providers, Payers, Policymakers and Patients Aligned in Care Transformation, the series of meetings will begin fall 2025 and run through spring 2026 with the goal of collaboration and consensus, not confrontation.

“We want to break the barrier and build a new bridge,” says Johnson. “Come together, agree on meaningful measures and rules anchored in evidence, and investigate patient outcomes and total cost. That’s how we protect patients, reduce burden on clinicians and effectively move the needle on healthcare value.”

Other Johns Hopkins researchers involved in this work include Jacob Murphy, Norman Beauchamp, Kristi Sun, Sarah Conway and Peter Hill.

No authors declare conflicts of interest.