It’s Time to Rethink Prior Authorization for Chronic and Serious Conditions

A breast cancer diagnosis 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 But for many patients, the journey to treatment begins with delays, often caused by outdated prior authorization (PA) processes.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, antiquated prior authorizations slows treatment, frustrates providers, and erodes 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 chasing approvals. And the healthcare system loses sight of its purpose: delivering the right care at the right time.

A smarter model for chronic conditions

Care pathways offer a smarter alternative. Using clinical-first AI and workflow automation, the platform shifts the focus from transactional, don’t-know-the-provider-or-the-patient-history-or-urgency approvals to clinical aligned intelligent approval bundles that help ensures care follows evidence-based guidelines, reduces unnecessary friction, and helps to ensure timely care.

Care pathways

Doing away with prior authorization is not the answer. In fact, according to research,“PA has been touted as a way to encourage high-value and cost-efficient budget allocation in oncology. When implemented in the context of treatment guidelines aligned with best practice, PA policies have the potential to increase the quality of cancer care.”

Guideline directed care pathways are a way to shift from transactional PA, where each service requires separate approval, to an episode-of-care model. Because care pathways are built on clinical guidelines and health plan medical policies, a pre-approved set of services tied 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 condition like breast cancer. Using claims and diagnosis codes, the health plan confirms eligibility for the pathway.
2. Evidence-based pathway: The patient’s clinical team recommends the current evidence-based treatment.
3. Automatic approval: Once enrolled, all services on that pathway are auto approved in real time.
4. Exception management: If a patient’s care requires services outside the pathway (for example, a genetic marker that alters treatment), those requests follow the traditional PA processes.

Centered on the patient

A traumatic diagnosis like breast cancer sets off a cascade of decisions, appointments, and treatments. In the current system, each step often requires a separate prior authorization, sometimes 15 to 20 times a year. Even with a “fast” three-day turnaround, that adds up to 45 days of waiting; 45 days of uncertainty and delay when every moment matters.

With pathways, that appointment can be made before leaving the office. This shift reduces the suffering caused by delays, reduces the risk of abandoned 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 deviation from the evidence-based pathway, exception-based prior authorization ensures the necessary review without compromising speed or quality. This approach balances consistency with personalization, allowing care teams to adapt while maintaining alignment with treatment standards.

Beyond breast cancer

While breast cancer is the logical starting point, other cancers, such as prostate and colorectal, have similarly well-established treatment protocols. Chronic conditions 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 necessary care.

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

Photo: Urupong, Getty Images

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