Heart failure remains one of the most serious cardiovascular conditions, affecting millions of adults worldwide and carrying a five-year mortality rate between 40 and 60 percent. Modern medical therapies, such as angiotensin receptor neprilysin inhibitors (ARNIs) and sodium-glucose cotransporter 2 inhibitors (SGLT2is), have been shown to significantly improve survival and reduce hospitalizations when added to standard heart failure treatment. Despite these benefits, many patients face barriers in obtaining these medications. A growing body of research suggests that prior authorization requirements may contribute to delayed or incomplete access to these therapies.
Prior authorization is a process used by insurance companies to approve certain prescription medications before a patient can receive them from a pharmacy. The process is intended to control costs and ensure medications are prescribed appropriately. Healthcare providers must submit documentation demonstrating medical necessity, and a decision must be made by the insurer before the patient can access the medication.
While prior authorization can help reduce unnecessary use of expensive drugs, it can create delays for patients who require treatments that are potentially life-saving. ARNIs and SGLT2is, which currently have no generic alternatives, may be particularly vulnerable to this issue. In addition, prior authorization can place an administrative burden on healthcare providers, leading to treatment delays or even treatment abandonment.
A study published in JACC: Advances examined the impact of prior authorization on patients with heart failure who were newly prescribed ARNIs or SGLT2is. The study included 2,183 patients from a large academic health system in the United States, combining electronic health records, pharmacy fill data, and neighborhood-level socioeconomic information. The research aimed to determine whether prior authorization requirements were associated with delayed or incomplete prescription fills.
The study revealed that prior authorization significantly affects the timing and likelihood of prescription fulfillment:
The study highlighted important disparities in access to heart failure therapies. Black and Hispanic patients, as well as those living in neighborhoods with lower socioeconomic status, were disproportionately affected by prior authorization requirements. These populations already experience higher rates of heart failure complications and mortality, suggesting that administrative barriers may worsen existing healthcare inequities.
Neighborhood-level socioeconomic status was measured using a composite index incorporating variables such as income, education, property values, unemployment, and poverty levels. Patients from areas with fewer resources were more likely to encounter prior authorization requirements, emphasizing how administrative policies intersect with social determinants of health to impact access to care.
Delayed or incomplete access to ARNIs and SGLT2is can have serious consequences for patients with heart failure. These medications are guideline-recommended for patients with reduced ejection fraction and are associated with substantial reductions in hospitalizations and mortality. When prior authorization requirements slow or prevent access to these therapies, patients may face increased risk of adverse outcomes.
Clinicians report that prior authorization can be a major obstacle in prescribing guideline-directed medical therapies. In surveys, many physicians noted that prior authorization leads to delayed treatment or even abandonment of therapy. The administrative burden can also discourage clinicians from prescribing potentially life-saving medications, which may further reduce access for vulnerable populations.
This research utilized a unique dataset that linked electronic health record data with pharmacy fill information. This approach allowed the researchers to track prescriptions that were never filled, rather than only analyzing filled prescriptions as is common in administrative claims studies. The dataset also included multiple insurance types, enabling an assessment of prior authorization across a diverse patient population.
By using advanced statistical techniques, including inverse probability weighting, the study adjusted for differences in age, sex, race, ethnicity, language preference, comorbidities, ejection fraction, prior hospitalizations, and neighborhood socioeconomic status. This robust methodology provides strong evidence for the association between prior authorization and reduced access to ARNIs and SGLT2is.
The study has several limitations. First, it was conducted within a single academic health system, which may limit generalizability to other regions or healthcare systems. Data on prior authorization were not available for all patients, and there may be residual confounding related to insurance type and other unmeasured factors. The study could not capture the detailed administrative process for each prior authorization, such as denials, resubmissions, or appeals, making it difficult to determine precisely why some prescriptions were never filled.
Despite these limitations, the findings are consistent with other studies in different medical specialties, including oncology, rheumatology, and gastroenterology, which have also observed delays and reduced access due to prior authorization.
The evidence suggests that prior authorization policies, while intended to reduce costs, may unintentionally worsen health disparities. Policymakers and healthcare organizations should consider strategies to minimize administrative barriers for life-saving therapies, particularly for patients from historically underserved communities. Potential solutions could include streamlined approval processes, electronic prior authorization systems, and policy reforms that exempt guideline-recommended medications with strong evidence of mortality benefit from prior authorization requirements.
Healthcare providers can also play a role by proactively identifying patients at risk of delayed therapy and assisting with prior authorization requests. Patient education and support services can help ensure that prescribed medications are obtained and taken as directed.
Further research is needed to examine the broader effects of prior authorization on medication adherence, clinical outcomes, and healthcare utilization. Studies could explore whether simplifying prior authorization processes improves prescription fulfillment and reduces disparities in treatment. Understanding the impact of prior authorization on provider prescribing behavior is also important, as administrative burden may discourage clinicians from recommending evidence-based therapies.
Additionally, research examining regional and insurance-related variations in prior authorization policies can inform targeted interventions. Collaboration between insurers, healthcare providers, and policymakers may help balance the need to control costs with the imperative to provide timely access to life-saving therapies.
Prior authorization requirements are associated with significant delays and decreased likelihood of filling prescriptions for ARNIs and SGLT2is, two medications that are essential for improving survival in patients with heart failure. These barriers disproportionately affect Black and Hispanic patients and individuals living in lower socioeconomic neighborhoods, exacerbating existing disparities in cardiovascular care.
Addressing administrative obstacles, particularly for medications that are strongly guideline-recommended, is a critical step in improving access to care and reducing preventable heart failure complications. Streamlining prior authorization processes and considering policy reforms may help ensure that all patients can receive timely, evidence-based therapy.
Improving access to life-saving medications is not only a matter of cost management but also a question of equity and patient outcomes. Ensuring timely access to ARNIs and SGLT2is has the potential to save lives and reduce disparities in cardiovascular health across populations.
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Disclaimer
This blog is intended for educational and informational purposes only and should not be considered medical advice. Patients should consult a healthcare professional for diagnosis and treatment recommendations. The content reflects research findings and general knowledge as of 2026 and may not reflect the most recent guidelines or individual patient circumstances.
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