Objective To measure and compare the scope of US insurers’ policies for prior authorization (PA), a process by which insurers assess the necessity of planned medical care, and to quantify differences in PA across insurers, physician specialties, and clinical service categories. Design Cross sectional analysis. Setting PA policies for five insurers serving most of the beneficiaries covered by privately administered Medicare Advantage in the US, 2021, as applied to utilization patterns observed in Medicare Part B. Participants 30 540 086 beneficiaries in traditional Medicare Part B. Main outcome measures Proportions of government administered traditional Medicare Part B spending and utilization that would have required PA according to Medicare Advantage insurer rules. Results The insurers required PA for 944 to 2971 of the 14 130 clinical services (median 1899; weighted mean 1429) constituting 17% to 33% of Part B spending (median 28%; weighted mean 23%) and 9% to 41% of Part B utilization (median 22%; weighted mean 18%). 40% of spending ($57bn; £45bn; €53bn) and 48% of service utilization would have required PA by at least one insurer; 12% of spending and 6% of utilization would have required PA by all insurers. 93% of Part B medication spending, or 74% of medication use, would have required PA by at least one Medicare Advantage insurer. For all Medicare Advantage insurers, hematology and oncology drugs represented the largest proportion of PA spending (range 27-34%; median 33%; weighted mean 30%). PA rates varied widely across specialties. Conclusion PA policies varied substantially across private insurers in the US. Despite limited consensus, all insurers required PA extensively, particularly for physician administered medications. These findings indicate substantial differences in coverage policies between government administered and privately administered Medicare. The results may inform ongoing efforts to focus PA more effectively on low value services and reduce administrative burdens for clinicians and patients. Additional data are available at .

中文翻译：

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保险公司的事先授权比较：来自 Medicare Advantage 的横断面证据


目的 衡量和比较美国保险公司的事先授权 （PA） 保单的范围，PA 是保险公司评估计划医疗护理必要性的过程，并量化保险公司、医生专业和临床服务类别之间 PA 的差异。设计 横截面分析。2021 年为美国私人管理的 Medicare Advantage 覆盖的大部分受益人的五家保险公司制定 PA 政策，适用于在 Medicare B 部分观察到的使用模式。参与者 30 540 086 传统 Medicare B 部分的受益人 主要结果指标 根据 Medicare Advantage 保险公司规则，政府管理的传统 Medicare B 部分支出和利用率需要 PA。结果 保险公司要求 14 130 项临床服务中的 944 至 2971 项（中位数 1899;加权平均值 1429）占 B 部分支出的 17% 至 33%（中位数 28%;加权平均值 23%）和 B 部分利用率的 9% 至 41%（中位数 22%;加权平均值 18%）。40% 的支出（570 亿美元、450 亿英镑、530 亿欧元）和 48% 的服务利用率将需要至少一家保险公司的 PA;12% 的支出和 6% 的利用率需要所有保险公司的 PA。93% 的 B 部分药物支出或 74% 的药物使用需要至少一家 Medicare Advantage 保险公司的 PA。对于所有 Medicare Advantage 保险公司，血液学和肿瘤药物在 PA 支出中所占比例最大（范围 27-34%;中位数 33%;加权平均值 30%）。PA 率因专业而异。结论美国私人保险公司的 PA 保单差异很大。尽管共识有限，但所有保险公司都广泛要求 PA，尤其是对于医生管理的药物。 这些发现表明，政府管理和私人管理的 Medicare 之间的承保政策存在很大差异。结果可能会为正在进行的努力提供信息，以更有效地将 PA 集中在低价值服务上，并减轻临床医生和患者的行政负担。其他数据可在以下网址获得.