New Prior Authorization Proposals: Implications for Prescription Drug Access

This episode of Health Affairs This Week explores the latest developments in prior authorization policy, focusing on a new CMS proposal to extend time limits for prior authorization decisions to prescription drugs—expanding a 2024 rule that previously applied only to surgeries and services. Michael Gerber, a returning guest, explains how the proposal aims to reduce administrative burdens on providers and payers, improve patient access to care, and accelerate the adoption of electronic prior authorizations through APIs and digital integration. The discussion highlights growing pressure on insurers to reduce overuse of prior auths, especially given that over 90% are approved and many denials are overturned on appeal. The episode also examines the dual-edged role of AI in prior authorization: while it promises to streamline workflows, early evidence suggests it may increase transaction volumes and costs, raising concerns about efficiency versus expense. Gerber notes that while federal rules apply broadly to Medicare Advantage, Medicaid, and ACA plans, commercial employer-sponsored plans remain largely unregulated, creating a fragmented landscape. Transparency and public reporting requirements are emerging as key tools for accountability and future research. Key takeaways include the importance of standardizing electronic prior authorization processes, the need to balance cost savings with potential AI-driven expenses, and the growing demand for data transparency to evaluate the real-world impact of prior auth policies. The episode underscores a rare alignment of incentives across patients, providers, and payers—where reducing unnecessary administrative hurdles can improve care access and system efficiency. Listeners are encouraged to explore Health Affairs Insider for deeper analysis and to stay informed on evolving policy and technology trends.