There is perhaps no phrase more triggering for physicians and their patients than prior authorization, the process by which insurance companies determine whether a treatment or procedure is medically necessary before agreeing to cover it. 

On average, physicians complete 34 prior authorizations every week, and 89% identify it as a leading contributor to burnout, according to the 2024 American Medical Association Prior Authorization Physician Survey. Most (92%) say it results in delayed treatment, and 29% say they’ve had patients who’ve suffered serious health events as a result. 

Now, a team of Johns Hopkins University School of Medicine faculty and trainees, led by the Office of Care Transformation, has published a meticulous two-year review of the relevant literature that shows beyond doubt what physicians have long suspected. Not only is prior authorization an expensive and time-consuming administrative burden, it is causing measurable and sometimes catastrophic patient harm. The team calls for more transparency from insurers, urging them to share valuable data on the outcome their decisions have on patient health, exposing their work to the same scrutiny already applied to the work of providers.

“It’s a black box when a health plan decides what can or can’t happen,” says study coauthor Brandyn Lau, associate professor of radiology and associate faculty in 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 of 25 studies, published in the American Journal of Medicine, spans multiple disciplines, from oncology and cardiology to behavioral sciences and pediatrics. In these studies, researchers found that the prior authorization process delayed or deprived patients of treatment for a wide range of serious conditions. Not only did many patients get sicker, the cost of their treatment often increased exponentially. Treatment delays caused preventable heart attacks in patients with cardiac conditions, and landed kids with asthma and inflammatory bowel disease in the emergency department.

“The review confirms what we already suspected,” says emergency department physician Peter Hill, a lead author of the study who is senior vice president, medical affairs, for the Johns Hopkins Health System. But Hill also sees the situation as an opportunity. “I think it’s important for health systems to be vocal in this space, to not just point out problems but to offer solutions,” he says.

A Fragmented System

Hill and his Johns Hopkins colleagues don’t believe insurance companies have set up roadblocks to care out of malevolence. The problem is rather the fragmentation of the health care system, involving multiple insurers and policymakers across the federal government and 50 states, all with different rules and histories and agendas.

“Collaboration is the key,” Hill says. “I think insurers and physicians and health systems all want to deliver the best care for patients, so my hope is that we can come together and allow the evidence to guide us,” he says.

The ultimate goal? “To create much more streamlined systems where the information presented to an insurer regarding a patient’s condition and need for a certain therapy or certain tests is brought forward crisply and cleanly in the medical record and satisfies agreed-upon criteria,” he says.

Hill and others believe insurers can benefit from the expertise and wherewithal of health systems like Johns Hopkins — which have the ability to incorporate appropriate use criteria, based on the best evidence-based medical practice, into their medical record systems. This could provide doctors and their patients with instant insight into the likelihood of a test or treatment being approved, enabling shared decision-making and ultimately relieving insurers of the burden of the prior authorization process.

“Health plans presumably have to pay a lot of money to build or purchase their own prior authorization programs. My hope is that if we embed clinical decision support in the electronic health record to evaluate whether medical decision-making is evidence-based, eventually the plans will partner with us to reduce their administrative and financial burden,” says radiologist Pamela Johnson, co-author of the study, who recently joined Sloan Kettering Cancer Center in New York. During her years leading high value care efforts for the Johns Hopkins Health System, Johnson’s team piloted an initiative, working with the Johns Hopkins electronic medical record system, to develop evidence-based criteria for ordering medical imaging. They reported their findings in in the Journal of the American College of Radiology in May 2022.

“We proved it can be done, but we still have the problem of dealing with multiple insurers, all with different rules and different degrees of transparency about how they formulate those rules,” she says. “And therein lies the opportunity and necessity for radical collaboration.”

Collaboration, Not Confrontation

The prior authorization literature review was phase one of the ambitious plan initiated by Johns Hopkins leaders to effectuate reform. Phase two is a six-month “convening” of patients, providers, insurers and policymakers from all over the country that Johnson planned with Laura Sigman, a physician and attorney who serves as executive director for strategic solutions at the Armstrong Institute for Patient Safety and Quality.

In partnership with colleagues from the Johns Hopkins University School of Medicine and collaborators from Johns Hopkins Carey Business School and Johns Hopkins Health Plans, they secured a Johns Hopkins Bloomberg Center Nexus Award to fund the convening, which was dubbed the PACT (Providers, Health Plans, Policy Makers, and Patients Aligned in Care Transformation).

The program kicked off in November and brought together more than 100 participants, representing insurers, policymakers, physicians, medical societies, health systems and patients from all over the country. The goal: to “create sustainable improvements in health care by aligning and synergizing the work” of these different stakeholders.

The keynote speaker at the November event, held at the Bloomberg Center in Washington, D.C., was Rebecca Stone, whose work encapsulates the problems inherent to a fragmented health care delivery systems. Stone, who is director of the Kelly Gynecologic Oncology Service at Johns Hopkins, is a leader in the prevention and treatment of ovarian cancer and has launched a project with the potential to dramatically reduce the risk of this deadly disease by as much as 80%.

“Research over the past 20 years has shown that most ovarian cancers, especially the most virulent form, originate in the fallopian tubes,” says Stone. “Removing the tubes while preserving the ovaries through a simple procedure called salpingectomy creates a powerful new opportunity for preventing ovarian cancer — a cancer that has no effective screening and is rarely curable. The problem is, most people don’t know about this, and educating not only patients and their doctors, but every policymaker and health plan in the country, is a daunting project.”

“As we embark on a major educational drive alongside the American Cancer Society, the last thing I want to do is raise awareness about something people can’t get access to. We need a multisector systems transformation,” she says.

So, the PACT convening is “genius, and incredibly timely, because figuring out the math, the cost/benefit of these things, not to mention how to go about overcoming the barriers to change, is hard. It’s much, much better to have a go at it proactively with everyone at the table,” she says.

Attendees at the daylong November event broke up into six workgroups of 10 to 20 participants to meet monthly on Zoom. Their projects included Stone’s ovarian cancer prevention initiative, streamlining breast cancer diagnosis, how to better measure the quality of inpatient care, and how providers might partner with payers on quality metrics and prior authorization reform.

“It’s incredibly powerful to see patients and patient representatives at the table with people from the health plans, each learning what the other has to deal with, and eager to collaborate on solutions,” Sigman says.

Together, the PACT participants hope to identify the nexus between the interests of insurers, health care quality assessment organizations and policymakers in controlling costs and the interests of providers and patients in accessing the most effective medical care. They will report back to Washington, D.C., in May 2026 with their conclusions.

“Our goal is alignment, and really meaningful alignment, across stakeholders,” Johnson says. “We’re breaking everything down and hoping to measure and improve the quality of health care delivery across the whole ecosystem, so it’s a really novel approach. We want to show that this kind of collaboration is the way forward, and we see this convening as just the beginning.”