Prior authorization isn't broken. It's unmeasured

UnitedHealthcare recently announced it would eliminate 30% of its prior authorization requirements and two-thirds of requirements for members under age 18. Other major insurers have made similar pledges. These changes are meaningful but incomplete. Counting the requirements that have been removed doesn’t measure what actually matters: Whether patients are getting care faster and whether providers are drowning in meaningless paperwork. Patients, providers, policymakers — and the plans themselves — need a single, comparable metric that captures both the effectiveness and the administrative burden of a health plan’s prior authorization process.

Four prior authorization metrics are already publicly reported for Medicare Advantage, Medicaid and Affordable Care Act (ACA) exchange plans under federal transparency rules, but each captures only one dimension of a plan’s program.

Prior authorization volume reflects how broadly a plan applies its review. Approval rates show how often requested care is approved while denial and overturn rates indicate whether denials reflect sound clinical judgment or are later reversed on appeal.

Combining these four metrics into a single “Friction Index” provides a more complete picture of prior authorization performance, capturing not only how frequently plans require it, but also how thoroughly and accurately they review requests for medical services and whether the benefits justify the burden imposed on patients and providers.

Getting that balance right is imperative. A 2025 systematic review led by Johns Hopkins researchers and published in The American Journal of Medicine found prior authorization was associated with measurable patient harm, including delayed care, worsening disease and preventable hospitalizations. But with healthcare spending approaching 18% of the gross domestic product, insurers need tools like prior authorization to help limit unnecessary or excessively costly care. A well-designed prior authorization program concentrates on high-cost, high-variability services where review can add genuine clinical and financial value.

Using publicly available CMS data, I calculated the Friction Index for 155 Medicare Advantage contracts with more than 5,000 members. The average score was 1.4, but the variation is striking. For example, among Blue Cross Blue Shield Medicare Advantage plans, scores range from 0.02 to 7.68, despite sharing the same national brand. The variation suggests plans are operating with vastly different thresholds for when prior authorization is appropriate and how it should be applied.

The most consequential finding from the analysis concerns the very outcome that prior authorization is designed to curtail: cost. Across the full dataset, the medical-loss ratio—the

share of premiums spent on patient care – shows virtually no correlation with Friction Index scores. In other words, plans with the most burdensome prior authorization programs are not spending meaningfully less on care than plans with lower friction programs.

If more aggressive prior authorization programs are not associated with lower medical spending, health plans are merely imposing administrative burden on patients, providers, and even on themselves, as payers. Health plan resources devoted to low-value prior authorization reviews are resources that are diverted away from other clinical programs that improve outcomes while also helping control costs.

The Friction Index provides a framework for evaluating whether a prior authorization program delivers sufficient value to justify its tradeoffs across the healthcare system.

For health plans, it is a management tool to identify opportunities to reallocate resources. For patients, it offers another way to compare plans beyond premiums and provider networks. For providers, it provides a data-driven measure of administrative burden to help inform contracting decisions. For employers, it offers leverage to demand greater transparency from commercial plans. For policymakers, publishing the Friction Index alongside existing Medicare Advantage, Medicaid, and ACA exchange plan data would require no new reporting — only a commitment to make better use of information already available.

Prior authorization needs to be optimized, not eliminated. The Friction Index makes that optimization possible by combining four metrics that, individually, have always given health plans room to tell a partial story. For the first time, stakeholders across the system have a common measure of whether the process works. The data to report that measure already exists. What we need now is the will to demand it.

Archelle Georgiou, M.D., served as chief medical officer of UnitedHealthcare from 1995 to 2007. She hosts the podcast and Substack newsletter “Speak Up for Your Health,” where the full Friction Index methodology and plan-level scores are available.