Delayed Health Care: How Paperwork Hurts American Physicians and Patients

Scrolling through my ‘For You’ Page on TikTok, I came across a video of a girl explaining how she begged to not be taken in an ambulance in fear of the bill that would come as a result. This wasn’t a unique experience as the hundreds of comments revealed the same fear many have, regarding hospital bills. One comment stood out to me, with over sixteen thousand likes which stated “It seems that fearing hospital bills over our health is a canon event. A canon event" can be described as an "unavoidable life event that builds character". Why has fearing health care become an unavoidable event? 

The extreme prices of basic medical care and even a doctor's visit has become an American norm. Healthcare in the United States is a booming industry making billions of dollars, profiting more than the care received by patients despite life expectancy being the lowest it's been in the past twenty years. The largest profiter, Health Insurance companies who have profited by billions of dollars, are also influencing patient outcomes. Adding on to the rising prices for patients, there has been an increase in delays and denials for patients to access medical care and treatment. 

Prior Authorization, is the administrative protocol that requires procedures, tests, or treatments ordered by physicians to be approved or “authorized” by insurance companies in order for patients to get such procedures covered by insurance. This means that insurance companies have the power to deny ordered procedures from trained medical professionals if they choose to. Basic medical imaging to life-saving treatments is not affordable for many Americans, averaging thousands of dollars. The only way a patient can access such unaffordable care is if their insurance pays for it- now if this insurance chooses to deny it, essentially they won’t receive the care needed for them to live. 

This procedure which initially started to approve excessive or long hospital stays has become a factor in patient outcomes. Nearly 1 in 4 physicians report that prior authorization has led to a serious adverse event for a patient. Such delays in procedures have even led to patient hospitalization, permanent bodily damage, and disability. 

When insurance providers choose to deny procedures, medical providers have the option to appeal it. This is the only way a patient can receive their needed care without spending out of pocket. However, this process is lengthy paperwork that takes up the valuable time physicians could be spending with patients. Physicians and their staff spend 12 hours each week solely on Prior Authorizations. After spending years on training how to care for patients, time everyday is instead lost on paperwork stopping them from giving their patients proper care. Time is not the only thing being lost, where the United States is estimated to spend 35 billion dollars on the costs of prior authorizations. Prior authorization is essentially counterproductive and overused to the extent it harms patient care and physician abilities. 

Physicians report that Prior Authorization rarely is evidence-based and 93% feel that prior authorization has somewhat or significantly had a negative impact on patient clinical outcomes. The healthcare system is supposed to serve the patient but is instead serving

companies who find administrative tactics to improve their own profits. Healthcare has become a market good where over time normalizing its inaccessibility has only led to further decrease in a patient's quality of life or no life at all. 

Why is a process that has been shown to do more harm than good to patients and physicians enabled and continued? 

If you hadn’t guessed, it increases profits for insurance companies. Insurance companies defend the role of Prior Authorization by claiming that the process reduces the cost of expensive treatments by trying lower-cost alternatives, avoiding dangerous medication combinations, and avoiding unnecessary procedures. This does point to a larger issue on the pay physicians receive based on the procedures given out which incentivizes costly procedures. However, prior authorization itself has become a common way for insurance companies to avoid paying for costly procedures even when it is life-saving. Delaying care is essentially a “net financial benefit” for insurers and a “net loss” for physicians. 

Recently, burdened patients and physicians speaking out have prompted some change. In late 2023 insurers UnitedHealthcare and Cigna put in plans and started to decrease the procedures requiring a prior authorization. By lowering the volume of prior authorizations physicians look to find relief from their administrative burden. This being said, this was a minor change and many physicians continue to spend time and resources on administrative requirements rather than their patients. This is why another proposed solution is for insurance companies to reimburse physicians based on the time they spend on insurance-required approvals. This solution does incentivize lower prior authorizations, contrasting to the current financial gain insurers get with more PAs. Insurance companies are likely to be reluctant towards this solution as it costs them more. With government support, insurers could be legally mandated to reimburse physicians though that is a process that will likely take years but can happen with enough support. Progress is being made where over 90 bills have been introduced to 30 states most of which attempt to decrease patient strain due to PAs. These small steps are in the right direction however only reveal more room for change. 

Other physicians are approaching administrative burdens in their own way. Using new technology and generative AI, physicians have been able to draft paperwork in seconds instead of hours. There are even HIPAA-compliant versions of ChatGPT that reduce the time and resources physicians have to spend on prior authorizations. Even better, this method has increased the approvals insurers give. However, barriers remain as not every physician is well-versed in these new approaches, and insurance companies themselves are looking into ways to utilize AI, which could potentially contradict physician's efforts. While improving these burdens for patients physician by physician is great, it reveals what measures medical professionals have to go to for their patients; compensating for a lacking health care system. 

Prior Authorization policies are only one of the various barriers that American healthcare often infringes on patients as well as providers. In these policies, a major theme is the lack of patient prioritization. Ironically, healthcare policies regard patients less than they consider profit. Years of legal battle, negotiating, and advocating are needed just to make small changes revealing a flawed structure and entertaining the wrong motives. Efficient and effective health care will only be possible when incentives and measures are implemented that look at patients first, then the profits that follow.