Adverse effects of health plan prior authorization on clinical effectiveness and patient outcomes: A systematic review

Jacob Murphy; Norman Beauchamp; Kristi J Sun; Brandyn D Lau; Renee F Wilson; Katie Lobner; Sarah J Conway; Peter M Hill; Pamela T Johnson

doi:10.1016/j.amjmed.2025.08.018

Adverse effects of health plan prior authorization on clinical effectiveness and patient outcomes: A systematic review

Am J Med. 2026 Jan;139(1):24-32.e1. doi: 10.1016/j.amjmed.2025.08.018. Epub 2025 Sep 3.

Authors

Jacob Murphy¹, Norman Beauchamp², Kristi J Sun², Brandyn D Lau³, Renee F Wilson⁴, Katie Lobner⁵, Sarah J Conway⁶, Peter M Hill⁷, Pamela T Johnson⁸

Affiliations

¹ Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
² Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
³ Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD, USA; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA.
⁴ Evidence-Based Practice Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
⁵ Welch Medical Library, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
⁶ Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Johns Hopkins Health System, Baltimore, MD, USA.
⁷ Johns Hopkins Health System, Baltimore, MD, USA; Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
⁸ Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Johns Hopkins Health System, Baltimore, MD, USA; Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA. Electronic address: pjohnso5@jhmi.edu.

PMID: 40912445
DOI: 10.1016/j.amjmed.2025.08.018

Abstract

Prior authorization requirements by health insurance plans have become a barrier to healthcare delivery in the United States in terms of clinical efficiency, patient and provider experience. Surveyed physicians report associations with care delays, reduced clinical effectiveness and compromised patient outcomes. In this systematic review, we synthesized the published evidence regarding harmful effects of prior authorization on disease management and patient outcomes. Twenty-five studies were included. In addition to care delays, authorization requirements were associated with disease exacerbation, preventable hospitalization, prolonged hospital stay, and lower rates of disease-free survival. Studies spanned multiple specialties including oncology, cardiology, behavioral health and pediatrics. Published evidence shows that prior authorization requirements are associated with measurable patient harm across multiple healthcare domains. Recognizing that a small number of retrospective studies do not adequately quantify the harm, we propose establishing national quality metrics for health plans, using claims data to track longitudinal outcomes in patients subject to delays and denials.

Keywords: Health outcomes; Health services; Prior authorization; Quality improvement; Systematic review.

Publication types

Systematic Review

MeSH terms

Humans
Insurance, Health*
Prior Authorization*
United States