New Research Finds Prior Authorization Fails to Cut Costs for Hip Replacement Surgery and Harms Patients

A new study presented at the 2025 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS) raises significant concerns about the effectiveness of prior authorization in managing costs for total hip arthroplasty (THA). Commonly used among commercial insurers, this protocol is aimed at controlling expenses; however, the findings indicate that it does not achieve its intended goals and instead complicates patient care.

The research titled "Prior Authorization Does Not Reduce Costs in Patients Undergoing Primary Total Hip Arthroplasty" highlights that although prior authorization is aimed at cost containment, it results in longer wait times, lower preoperative functional outcomes, and added administrative challenges for healthcare providers. The lead author of the study, Elizabeth Abe, BS, MS4, emphasized that the increase in bureaucracy associated with prior authorization could lead to patients abandoning necessary care when their surgery is initially denied or prolonged, ultimately exacerbating their condition.

According to the data, hip osteoarthritis (OA), particularly among individuals aged 50 and older, often necessitates THA as the cartilage degrades, leading to significant pain and disability. Each year, approximately 544,000 THAs are performed across the United States, and with an aging population, the demand is likely to grow. Prior authorization often mandates that patients undergo a series of conservative treatments—ranging from physical therapy to anti-inflammatory medications—even when surgeons believe these steps are futile. Such requirements can lead to frustrating scenarios where delays in necessary surgical intervention occur, as seen from a survey by the American Medical Association where 93% of physicians reported that prior authorization processes have hindered patient treatment.

The study meticulously analyzed a cohort of 3,922 patients undergoing unilateral, primary THA for end-stage hip OA from January 2020 to December 2022. Of these, a significant proportion (72.4%) were subjected to prior authorization, revealing a twofold likelihood of experiencing surgery denial compared with their counterparts. The patients who required prior authorization typically had not only worse pre-surgery functional scores but also faced longer delays in receiving treatment.

Surprisingly, obtaining prior authorization was correlated with extended wait times before THA, increasing the timeline to surgery by approximately 2.1 days. The adverse effects of the cumbersome process extend beyond mere delays; patients with prior authorization reported significantly lower hip dysfunction scores before their surgery, indicating that their condition deteriorated while waiting for approvals.

Dr. Chad A. Krueger, an orthopaedic surgeon at Rothman Orthopaedics, asserted that the current prior authorization system fails to deliver on its promise of cost-saving while simultaneously increasing the administrative workload on healthcare providers. He pointed out that this process delays necessary surgeries, compelling patients to confront worsening conditions that might have been alleviated through timely intervention. Many patients ultimately face unnecessary suffering and increased treatment costs, perpetuating a cycle of administrative hurdles that do not serve their health needs effectively.

On the administrative side, the findings from the study also illuminate the financial burden associated with prior authorization processes. Based on prior research by Sahni et al, it was estimated that each submission for prior authorization incurs costs of $40 to $50 for insurers and significantly reflects back to the practices, which can hover around $20 to $30, further perpetuating the inefficiencies within the healthcare system. Thus, the administrative costs and the disruption caused by the complexities of prior authorization could significantly offset any supposed financial benefits that insurers claim to achieve.

As the healthcare landscape continues to evolve, these findings provide a critical impetus for a re-evaluation of prior authorization policies, particularly concerning essential surgical procedures like THA. Stakeholders, including surgeons, patients, and lawmakers, need to engage in constructive dialogue to refine the authorization process to improve patient care timelines and outcomes. Given the evidence of patient distress stemming from these protocols, it is paramount for the healthcare community to advocate for changes that prioritize patient health and straightforward access to necessary treatments over cumbersome administrative processes.

To address these challenges, it is essential for policymakers and stakeholders to rethink the current practices surrounding prior authorization. Tailored solutions are urgently needed to align cost-containment strategies with the vital need to deliver timely, evidence-based medical care to patients, mitigating the risks associated with delaying necessary procedures such as total hip arthroplasty.