Few tools in healthcare are as essential — or as misunderstood — as prior authorization. Designed to protect patients from overly expensive or unnecessary care, prior authorization has become a flashpoint in policy debates nationwide.
Let’s examine what happens when the healthcare system fails to provide adequate checks on patient care. The opioid epidemic began due to the overprescribing of highly addictive painkillers. In 2012, according to a study by the Centers for Disease Control and Prevention, there were more opioid prescriptions than people in Ohio.
Having spent three decades in healthcare, I’ve seen how prior authorization, when used thoughtfully, safeguards patients and promotes high-value care. Behind every managed care process is a team of clinicians committed to ensuring that care is safe, effective and necessary.
Efforts to dismantle prior authorization overlook the unintended consequences that threaten patient safety, increase costs, and lead to worse outcomes. It’s time to take a clear look at what prior authorization is, what it’s not, and how it can be improved.
Prior authorization focuses on areas that require closer scrutiny, particularly high-cost, high-risk or emerging therapies. It helps ensure that treatments offer real value to patients, not just in terms of cost but in their ability to improve lives. By putting patients at the center of what prior authorization does, we can work to make the system better for those who need it.
I remember when bone-marrow transplants were widely used for unresponsive breast cancer, despite little evidence to show they worked. There were lots of passionate appeals from doctors and patients, and legislators were sometimes involved when these cases were denied. In fact, the evidence was bad, and bone marrow transplants did more harm than good. Effective prior authorization prevents these missteps, helping clinicians stay aligned with the latest evidence-based medical guidance.
More recently, the availability of GLP-1 (weight loss) medications has been strained by off-label demand for cosmetic weight loss. In Ohio, more than 1.7 million individuals were prescribed GLP-1s last year. Prior authorization helps ensure these vital therapies remain accessible to patients who critically need them to manage conditions such as diabetes.
Beyond patient safety, the financial benefits are significant. Prior authorization helps manage rising healthcare costs by guiding patients toward effective generic drugs, reducing out-of-pocket prescription expenses by up to 80 percent when equivalent generics are used. This means that patients get the care they need without facing exorbitant medical costs.
Prior authorization is not perfect, and we can improve it by making the process faster and more transparent. As we consider new policies, we cannot lose sight of why prior authorization exists and how we can make it work better. Eliminating prior authorization would only expose patients to unnecessary risks, medical and financial.
Sound policy must be pragmatic, safeguard the foundations of patient well-being, and keep the healthcare system strong.
