Prior authorization (PA) has been implemented by payors in an effort to reduce unnecessary healthcare utilization. However, obtaining PA has been shown to increase the administrative burden and delay access to care. To our knowledge, the financial burden and cost-effectiveness of PA in total hip arthroplasty (THA) is yet to be determined. The purpose of this prospective study was to quantify the costs associated with obtaining PA in primary THA patients.
Methods
A consecutive series of 3,922 patients undergoing primary THA with commercial insurance from a single payer from 2020-2022 at a single institution were included. Data on PA status, the number of office visits, and total claims cost of nonoperative treatment received in the year prior to THA and from the initial PA request date to date of surgery was prospectively collected and analyzed.
Results
Of the study population, 2,840 (72.4%) patients required PA. There was no difference in the mean claims cost in the year prior to THA ($316 ± 234 in PA vs. $318 ± 273 in the no PA cohort, P=0.760) and from initial request date to date of surgery ($318 ± 249 in PA vs. $302 ± 245 in no PA cohort) between the 2 groups (P =0.430). However, patients that required PA were found to have significantly lower preoperative HOOS-JR scores (48.1 ± 15.5 vs. 49.7 ± 14.7, P =0.021) and experienced a significantly longer duration from initial surgery request date to date of THA (40.4 days ± 37.0 vs. 38.7 days ± 36.0, P =0.023).
Discussions and Conclusions
In the present study, obtaining PA was found to be an ineffective cost-saving measure in patients undergoing primary THA. Additionally, THA patients who required PA not only had lower preoperative functional outcome scores, but also experienced significantly longer wait times prior to obtaining surgery.
Abe E, Lizcano JD, Tarabichi S, et al. Prior Authorization Does Not Reduce Costs in Patients Undergoing Primary THA. Presented at 2025 Annual Meeting of the American Academy of Orthopaedic Surgeons. San Diego, CA: March 10, 2025.
