Most prior-authorization harm is about time — the days a patient waits while paperwork moves. Rheumatology has that problem too, but it also has a sharper one: the evidence suggests the gating itself can make treatment work less well.
The mechanism is step therapy — the payer rule that a patient must fail cheaper drugs before reaching the one the rheumatologist chose.
The numbers in rheumatology
A 2019 analysis in PharmacoEconomics Open (Boytsov et al., n=5,706) examined how access restrictions affected biologic therapy and found:
- 27% lower odds of treatment effectiveness in psoriatic arthritis under step therapy.
- 19% lower odds in rheumatoid arthritis.
These are outcome differences, not just scheduling differences. On top of them sits the universal burden: 39 authorizations per physician per week, about 13 hours lost to them, and 93% of physicians reporting that PA delays care (AMA 2024).
Why rheumatology is different
- Step therapy is the default. Biologics and JAK inhibitors are expensive, so payers require documented failure of one or more preferred agents first — forcing patients onto drugs the rheumatologist may already expect to underperform.
- Recurring re-authorizations. One approval isn’t permanent. Re-auths recur every few months, and a lapsed one means a disease flare while the paperwork catches up.
- Per-payer documentation. The same failure history and disease-activity scores have to be reassembled in each payer’s preferred shape.
- Clinician-time drain. Peer-to-peers pull rheumatologists off the floor to defend, by phone, a drug already proven in the literature.
What it costs
The cost in rheumatology is unusually direct: worse disease control for patients held on step therapy, plus the standing operational expense of assembling failure histories and re-authorizations — about $10.81 per manually processed authorization (CAQH 2023), recurring on every patient on a biologic. The clinical and the administrative costs compound: the longer the gating, the more flares, and each flare generates its own downstream paperwork.
How to cut the wait
The step-therapy packet is exactly the kind of structured documentation software should assemble. Artificer Health:
- Builds the step-therapy record — prior agents tried, failures documented, disease-activity scores, and the supporting clinical detail.
- Matches it to the payer’s policy so the submission satisfies that payer’s specific criteria on the first pass.
- Tracks recurring re-authorizations so therapy never lapses for an administrative reason and patients stay on the drug that works.
The goal is to get rheumatology patients to effective therapy faster — and to keep them there — instead of cycling them through documented failures to satisfy a form.
Sources: Boytsov et al., PharmacoEconomics Open 2019 (n=5,706); AMA 2024 Prior Authorization Physician Survey; CAQH 2023 Index.