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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各保险公司事先授权的比较：来自 Medicare Advantage 的横截面证据

目的 衡量和比较美国保险公司事先授权 (PA) 政策的范围（保险公司评估计划医疗护理的必要性的过程），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。为 2021 年美国私人管理的 Medicare Advantage 覆盖的大多数受益人提供服务的五家保险公司制定 PA 政策，适用于 Medicare B 部分中观察到的使用模式。传统 Medicare B 部分中的参与者为 30 540 086 名受益人。 主要成果指标政府管理传统的 Medicare B 部分支出和使用，根据 Medicare Advantage 保险公司的规则，这需要 PA。结果 保险公司要求 14 130 项临床服务中的 944 至 2,971 项（中位数 1899；加权平均值 1429）进行 PA，占 B 部分支出的 17% 至 33%（中位数 28%；加权平均值 23%），占 B 部分支出的 9% 至 41%。 B 部分利用率（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% 的服务利用率需要至少一家保险公司进行 PA；所有保险公司都需要 12% 的支出和 6% 的利用率进行 PA。B 部分药物支出的 93%，或药物使用的 74%，需要至少一家 Medicare Advantage 保险公司提供 PA。对于所有 Medicare Advantage 保险公司来说，血液学和肿瘤学药物在 PA 支出中所占比例最大（范围 27-34%；中位数 33%；加权平均值 30%）。不同专业的 PA 率差别很大。结论 美国私人保险公司的 PA 政策差异很大。尽管共识有限，但所有保险公司都广泛要求 PA，特别是对于医生给药的药物。这些发现表明政府管理的医疗保险和私人管理的医疗保险之间的承保政策存在巨大差异。结果可能会为正在进行的努力提供信息，使 PA 更有效地专注于低价值服务，并减少临床医生和患者的行政负担。其他数据可在。