SAN
DIEGO, March 10, 2025 /PRNewswire/ -- Prior
authorization is commonly used with commercial insurance companies
as a cost-controlling policy. However, a study presented at the
2025 Annual Meeting of the American Academy of Orthopaedic
Surgeons (AAOS) found that prior authorization was an
ineffective cost-saving measure for patients undergoing primary
total hip arthroplasty (THA). The study, "Prior Authorization Does
Not Reduce Costs in Patients Undergoing Primary Total Hip
Arthroplasty," also saw lower preoperative functional outcomes
scores and significantly longer wait times before surgery when
prior authorization was required. It is the first study to quantify
the time and costs associated with obtaining prior authorization in
patients undergoing THA.
"Prior authorization is employed more frequently for various
orthopaedic procedures, and it is forcing an added administration
burden on healthcare practices," said Elizabeth Abe, BS, MS4, lead author of the
study. "This not only increases the time to get a patient approved
for the procedure, but it ultimately leads to delays in patient
care. If insurance denies a patient's surgery, sometimes the
patient will give up and live in pain. Patients may try other
nonoperative treatments that eventually fail them, and then the
patient is spending more time and money to fail procedures that
don't change the course of their treatment. Many times, they still
need a total hip replacement."
Hip osteoarthritis (OA) is an age-related wear and
tear type of arthritis that typically affects those 50 years of age
and older and causes deterioration of the cartilage of the hip
bone. This causes pain and stiffness and may eventually lead to
end-stage OA, which is when the cartilage is almost gone and there
is chronic inflammation.i Those with hip OA may
eventually require THA. There are approximately 544,000 THAs
performed each year in the United
States and the procedure is growing as the population
ages.ii
Oftentimes, insurance companies require patients to trial and
fail a specified series of physician-documented, conservative
therapies, including physical therapy (PT), muscle strengthening
exercises, weight reduction, therapeutic injections, or
anti-inflammatory medications, even if the surgeon believes these
nonoperative treatments won't be beneficial to the
patient.iii If the insurance company denies coverage,
surgeons may be required to participate in a peer-to-peer (P2P)
review with representatives from the insurance company. This can
cause delays in patient care. In fact, in a 2023 survey by the
American Medical Association, 93% of physicians surveyed said this
prior authorization process had delayed their patients' treatments,
78% believed delays due to prior authorization led their patients
to abandon necessary care, and 24% stated that delays from prior
authorization led to avoidable, serious adverse
events.iv
Prior authorization for THA shows no cost-saving
benefits
The study included patients who underwent
unilateral, primary THA for end-stage hip OA from January 2020 through December 2022 and were insured by a single,
commercial payor. Patient-reported outcome measures (PROMs) that
included the hip dysfunction and OA outcome score for joint
replacement (HOOS-JR) and 12-item short form physical component
score (SF-12 PCS) were recorded preoperatively and at 6-month
postoperatively. Data recorded that was specific to the prior
authorization process included approval or denial status, days to
approval or denial, number of denials, number of P2P reviews or
addenda required, and denial reasons.
The primary outcome of the study was the cost associated with
obtaining prior authorization in patients that underwent primary
THA. These costs consisted of:
- Conservative therapies, diagnostic imaging, and office visits
required as part of the prior authorization process
- The costs incurred while patients waited to obtain
authorization and approval from their initial surgery request to
the date of surgery.
Secondary outcomes included time from surgery request date to
the date of THA, preoperative PROMs, and postoperative PROMs.
A total of 3,922 commercially insured patients were included,
including 2,840 (72.4%) patients whose insurance required prior
authorization before THA and 1,082 (27.6%) patients whose insurance
did not require prior authorization. Patients in the prior
authorization cohort were more likely to be younger, male, identify
as black, have an increased BMI and were more likely to undergo
surgery as an inpatient. Patients requiring prior authorization
also were more likely to have lower preoperative HOOS-JR scores
(48.1 ± 15.5 versus 49.7 ± 14.7) when compared to patients not
requiring prior authorization.
In the prior authorization cohort compared to the non-prior
authorization cohort, the findings included:
- Patients were more likely to experience denial on initial
request for THA (1.5% versus 0.0%).
- Surgeons were more likely to be required to participate in a
P2P review (0.6% versus 0.0%).
- An addendum was more likely to be submitted (9.4% versus 0.0%,
P<0.001) as requested when additional documentation was
necessary to determine prior authorization approval or denial.
- Patients more frequently experienced any form of denial (4.8%
versus 3.0%).
- Patients experienced significantly longer wait times from
initial surgery request date to the date of THA (40.4 ± 37.0 days
versus 38.7 ± 36.0 days).
- In the year preceding THA, significantly less patients in the
prior authorization cohort underwent x-ray imaging (63.8% versus
68.8%).
Obtaining prior authorization was found to increase time to
surgery by 2.1 days. A higher preoperative SF-12 PCS score was
found to decrease time to surgery by 0.3 days.
"The prior authorization process and the steps a patient has to
go through do not help save costs in the year prior to surgery,"
said Chad A. Krueger, MD, FAAOS,
orthopaedic surgeon, Rothman Orthopaedics in Philadelphia. "Patients whose insurance
required prior authorization were found to have significantly worse
HOOS-JR scores, which is a measure of how badly their hip feels, so
their hips felt worse before surgery, and they experienced longer
delays in getting to surgery than patients whose insurance did not
require prior authorization. We are delaying the inevitable and
jumping through hoops to get to surgery. Orthopaedic surgeons and
patients can use these findings as fuel to try to work with our
Congressional members on both sides of the aisle to improve the
prior authorization process."
The study authors noted that when P2P reviews, addendums and
changes in surgery designation from inpatient to outpatient were
required, this may explain the time delay THA patients with prior
authorization experienced and these additional steps may increase
the administrative costs associated with maintaining a
practice.
In a separate study by Sahni et al, each submission for prior
authorization was estimated to cost between $40 to $50 for
private payors and $20 to
$30 for surgeons with each claim
taking 4 to 6 weeks on average to process and pay.v That
study also found that for private payors, more than 90% of prior
authorization submissions were ultimately approved, further
questioning the efficiency and cost-efficacy of the prior
authorization process.
The researchers of the prior authorization study concluded that
the current process actively increases the administrative burden of
THA, contributing to delayed access to care with little
consideration of evidence-based treatment and when various
therapies would be most beneficial to patients.
2025 AAOS Annual Meeting Disclosure Statement
About the AAOS
With more than 39,000 members, the American Academy of Orthopaedic
Surgeons is the world's largest medical association of
musculoskeletal specialists. The AAOS is the trusted leader in
advancing musculoskeletal health. It provides the highest quality,
most comprehensive education to help orthopaedic surgeons and
allied health professionals at every career level best treat
patients daily. AAOS is the source of information on bone and joint
conditions, treatments, and related musculoskeletal healthcare
issues; and it leads the healthcare discussion on advancing
quality.
Follow the AAOS
on Facebook, X, LinkedIn and Instagram.
i American Academy of Orthopaedic Surgeons.
OrthoInfo. Osteoarthritis. Published April
2022. Accessed Jan. 30, 2025.
https://orthoinfo.aaos.org/en/diseases--conditions/osteoarthritis/
ii American College of Rheumatology. Joint Replacement
Surgery. Published February 2024.
Accessed Jan. 30, 2025.
https://rheumatology.org/patients/joint-replacement-surgery
iii Centers for Medicare & Medicaid Services. Loal
Coverage Determination. Total Hip Arthroplasty (L34163) Accessed
Feb. 6, 2025.
https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=34163.
iv American Medical Association. 2023 AMA prior
authorization physician
survey. https://www.ama-assn.org/system/files/prior-authorization-survey.pdf
v Sahni NR, Gupta P, Peterson M, Cutler DM. Active steps
to reduce administrative spending associated with financial
transactions in US healthcare. Health Aff Sch 2023;1:qxad053.
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SOURCE American Academy of Orthopaedic Surgeons
