HJBR Sep/Oct 2025

WHAT’S WRONG WITH HEALTHCARE 14 SEP / OCT 2025 I  HEALTHCARE JOURNAL OF BATON ROUGE   dations and terminating coverage prematurely. Many of these denials were overturned on ap- peal, raising concerns about the algorithm’s medical validity. A class action lawsuit filed by patients’ fami- lies alleges that these denials were made with- out proper clinical oversight and led to harmful care disruptions. The controversy has sparked broader debate over the ethical use of AI in healthcare decision-making and has drawn the attention of federal regulators seeking to strengthen oversight of prior authorization practices in Medicare Advantage. Recently, Health and Human Services Secre- tary Robert F. Kennedy Jr., and Mehmet Oz, MD, administrator of the Centers for Medi- care & Medicaid Services (CMS), convened a high-level roundtable with major health insur- ers — including Aetna, Cigna, Blue Cross Blue Shield, Humana, Kaiser Permanente, and Unit- edHealthcare — to secure a voluntary pledge aimed at overhauling the prior authorization system. As part of this commitment, insurers agreed to standardize electronic prior autho- rization using Fast Healthcare Interoperability Resources (FHIR)-based systems, reduce the number of services requiring prior authoriza- tion by January 1, 2026, and honor existing authorizations during insurance transitions to ensure continuity of care. The insurers also pledged to improve trans- parency and communication with patients and providers, clarify decisions and appeals pro- cesses, and move toward delivering real-time responses to authorization requests, with most approvals expected to occur instantly by 2027. Finally, the agreement requires that all clinical denials be reviewed by licensed medical pro- fessionals. Kennedy emphasized that patients and doctors should not have to “negotiate with their insurer to get the care they need,” describing the pledge as a step toward restor- ing trust in the system. Oz underscored that this is not legislation but a voluntary industry effort that “allows the industry to show itself,” while affirming that CMS will closely monitor progress and may pursue additional regulatory steps if insurers fail to follow through. Only time will tell if these promises will come to fruition. In the spirit of being fair and balanced, I would be remiss if I didn’t mention a recent study published in the Journal of Political Economy that examined the effect of a prior authorization policy on non-emergent ambu- lance rides for dialysis patients. The findings were striking: Even though the policy cut more than two-thirds of the roughly 200,000 monthly rides to and from dialysis facilities, this decline did not disrupt patient care or worsen health outcomes, indicating that many of these rides were likely unnecessary. The results underscore how prior authorization can help reduce avoid- able healthcare utilization while preserving quality of care. In short, prior authorization can function as it was intended, which is to avoid paying for services that are of low or minimal value while not compromising outcomes, and it has the potential to avoid putting profits over patients, however, given the evidence of widespread overutilization, some form of oversight is clear- ly necessary. But is preauthorization the right tool for clini- cal care? Its track record of delaying necessary care and burdening providers suggests other- wise. Perhaps Makary’s Improving Wisely initia- tive offers a more promising approach: using transparency, peer comparison, and clinical leadership — not denials — to drive change. When physicians see that they are outliers in their specialty, many adjust voluntarily. Rather than wielding preauthorization as a blunt instrument, we might achieve better re- sults by offering “gold card” status to providers who consistently deliver high-value, evidence- based care — and reserving prior authoriza- tion for those instances that are most strongly associated with profit-seeking behavior or for those providers demonstrating patterns of in- appropriate utilization despite peer feedback. Ultimately, the debate over prior authoriza- tion reflects the deeper struggle within Ameri- can healthcare: balancing cost control and ac- countability with timely, patient-centered care. Evidence shows that overutilization and low- value practices remain pervasive, yet the cur- rent preauthorization system often obstructs access to high-value care and erodes trust be- tween patients, providers, and payers. If reform efforts such as those recently pledged by na- tional insurers under federal scrutiny succeed, prior authorization may evolve into a more precise, clinically sound safeguard rather than a barrier. But if they fail, it will only reinforce the argument that economic incentives, not patient welfare, drive too much of our system. The path forward, then, is not to abandon oversight, but to reimagine it — leveraging data transparency, physician leadership, and value-based incen- tives so that accountability and compassion are no longer at odds. Only by aligning these forces can we begin to repair what is broken and create a healthcare system that truly serves patients first. n REFERENCES American Medical Association. “2024 AMA Prior Authorization Physician Survey.” https://www. ama-assn.org/system/files/prior-authorization- survey.pdf. American Medical Association. “Most Physicians Had Little Relief from Prior Authorization as COVID Cases Soared.” April 7, 2021. https:// www.ama-assn.org/press-center/ama-press- releases/most-physicians-had-little-relief-prior- authorization-covid-cases. Makary, M. A. The Price We Pay: What Broke American Health Care — and How to Fix It. Bloomsbury Press, 2017. Makary, M. A. Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care. Bloomsbury Press, 2012. McCrystal, Timothy. “Medicare Advantage Regulatory Scrutiny Keeps Pace with Growth: OIG Report Examines Prior Authorization and Payment Denial Errors.” Ropes & Gray, June 6, 2022. https://www.ropesgray.com/en/ insights/alerts/2022/06/medicare-advantage- regulatory-scrutiny-keeps-pace-with-growth- oig-report-examines. Moseley, J. B., et al. “A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee.” New England Journal of Medicine 347, no. 2 (2002): 81–88. Powers, B. W., et al. “De-adopting Low Value Care: Evidence, Eminence, and Economics.” Journal of the American Medical Association 324, no. 16 (2020): 1603–04. Ross, Casey, and Rob Herman. “How UnitedHealth’s Acquisition of a Popular Medicare Advantage Algorithm Sparked Internal Dissent Over Denied Care.” Stat, July 11, 2023. https:// www.statnews.com/2023/07/11/medicare- advantage-algorithm-navihealth-unitedhealth- insurance-coverage. Shrank, W. H., et al. “Waste in the US Health Care System: Estimated Costs and Potential for Savings.” Journal of the American Medical Association 322, no. 15 (2019): 1501–1509. Wennberg, J. E. Tracking Medicine: A Researcher’s Quest to Understand Healthcare, Oxford University Press, 2010.