It’s time to rethink prior authorization for chronic and serious conditions

A diagnosis of breast cancer should trigger immediate action. But for many patients, the journey to treatment begins with delays, often caused by outdated prior authorization (PA) processes. Designed to ensure appropriate care, outdated prior authorizations slow treatment, frustrate providers, and erode patient trust.

The problem is both technical and clinical. Because the system relies on phone calls, faxes and human intervention, care is delayed or abandoned, and patients and their families suffer. Providers spend hours researching approvals. And the health system is losing sight of its purpose: to deliver the right care at the right time.

A smarter model for chronic diseases

Care pathways offer a smarter alternative. Using clinical AI and workflow automation, the platform shifts the focus from transactional approvals, unaware of the provider or patient history or urgency, to clinically aligned sets of intelligent approvals that help ensure care follows evidence-based guidelines, reduce unnecessary friction, and help ensure on-time care timely.

Care pathway

Removing prior authorization is not the solution. In fact, according to research, “PA has been touted as a way to encourage high-value, cost-effective budgetary allocation in oncology. When implemented in the context of treatment guidelines aligned with best practices, PA policies have the potential to increase the quality of cancer care.”

Guideline-led care pathways are a way to move from transactional PA, where each service requires separate approval, to an episode of care model. Because care pathways are based on clinical guidelines and health plans’ medical policies, a set of pre-approved services linked to evidence-based guidelines are automatically authorized once a diagnosis is confirmed. Here’s how it works:

1. Identification: A patient is diagnosed with a serious illness such as breast cancer. Using claim and diagnosis codes, the health plan confirms eligibility for the pathway.
2. Evidence-based pathway: Patient’s clinical team recommends current evidence-based treatment.
3. Automatic approval: Once registered, all services in this course are automatically approved in real time.
4. Exception handling: If a patient’s care requires services outside of the pathway (e.g., a genetic marker that alters treatment), those requests follow traditional PA processes.

Patient-centered

A traumatic diagnosis like breast cancer triggers a cascade of decisions, appointments and treatments. Under the current system, each step often requires separate prior authorization, sometimes 15 to 20 times per year. Even with a “fast” three-day turnaround, that’s a 45-day wait; 45 days of uncertainty and delay where every moment counts.

With routes, this appointment can be made before leaving the office. This change reduces the suffering caused by delays, reduces the risk of abandonment of care and improves continuity, allowing treatment to move forward without administrative friction.

The pathway model also preserves clinical flexibility. When a patient’s care requires a deviation from the evidence-based pathway, an exceptions-based prior authorization ensures the necessary review without compromising timeliness or quality. This approach balances consistency and personalization, allowing care teams to adapt while maintaining alignment with treatment standards.

Beyond breast cancer

Although breast cancer is the logical place to start, other cancers, such as prostate and colorectal, have equally well-established treatment protocols. Chronic illnesses such as congestive heart failure, sickle cell disease, inflammatory bowel disease, and chronic kidney disease also fit the model: predictable, evidence-based pathways where prior authorization too often slows needed care.

The arguments in favor of chronic and serious care pathways are both logical and moral. Patients facing life-threatening or life-limiting conditions deserve better experiences. Providers deserve to spend their time caring for patients, not chasing approvals. And payers deserve a model that ensures evidence-based care is delivered to their members at the right time, without the burden of multiple unnecessary transactional authorizations.

Photo: Urupong, Getty Images

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