On Medicare Inefficiencies and Healthcare Waste

First published 13 November 2016 · revised August 2026. The complaint has aged well, which is not a compliment to anyone.

There has been a great deal of talk about reducing waste and inefficiency in healthcare as a way of controlling costs. It is a goal worth serious effort from patients, providers and administrators alike. I am most familiar with what happens on the provider side, and most of the physicians I have worked with are cost-conscious — avoiding duplicate tests, teaching prevention, trying to keep things lean.

Administrative paperwork is a different matter, and here is a small example of why.

The form

Medicare sent me a prior authorization form for a prescription I had written for a patient born in September of a year I have redacted, along with everything else identifying. Medicare knows this date. It is printed on the form, under “Patient DOB”.

A few lines further down, the form asks me to state whether the patient is two years of age or older.

In an era of electronic medical records — in which Medicare and the commercial insurers have made paperless documentation effectively mandatory for physicians and hospitals — it appears Medicare cannot subtract one date from another. Instead it asks the physician, whose time costs rather more than a line of code, to do the arithmetic.

Or perhaps nobody who designed the form ever spent a moment thinking about how long it takes to complete.

Small things add up

This is a trivial example. I chose it precisely because it is trivial — there is no clinical controversy in it, no trade-off to weigh, nothing to defend. It is simply a question that should never have been printed.

When I first wrote this I cited an industry estimate that simplifying administration could save around $300 billion a year. Better work has been done since, and the picture is worse than that figure suggested.

What it costs in hours

The abstraction becomes concrete when you count the time. The American Medical Association’s 2024 survey of a thousand physicians found:²

• 39 prior authorizations per physician per week, consuming about 13 hours — the better part of two working days.
• 94% reported that prior authorization delays patients’ access to necessary care.
• 29% reported that it had led to a serious adverse event for a patient in their care — hospitalisation, a life-threatening event, disability, or death.

That last figure is the one that should stop the conversation. This is not merely tedious. Nearly a third of physicians can name a patient who came to harm waiting for permission.

Thirteen hours a week per physician is not a paperwork problem. It is roughly a third of a clinician who no longer sees patients.

Ten years on: some actual progress

The original version of this article was titled, in effect, no progress seen. In fairness, that is no longer entirely true.

In January 2024, CMS issued the Interoperability and Prior Authorization Final Rule. From January 2026 affected payers — Medicare Advantage plans, Medicaid and CHIP managed care, and qualified health plans on the federal exchanges — must decide urgent requests within 72 hours and standard requests within seven calendar days, and give a specific reason for denials. By January 2027 they must run electronic prior authorization interfaces so the request can pass between systems rather than across my desk.³

I want to be measured about this. It is a genuine step, and the deadlines are real. It also took roughly a decade from the complaint to the rule, it applies to some payers and not others, and a seven-day standard is a ceiling rather than an ambition. Whether any of it reaches the examining room is a question I will answer when I see it.

Final thoughts

I have no grand thesis here. The system is enormous and most of its problems are genuinely hard, involving trade-offs between cost, access and quality that reasonable people dispute.

But some of it is not hard at all. Some of it is a form that already contains the answer to its own question. Those parts are worth pointing at, because they are the ones where nobody can claim it is complicated.

And, perhaps eventually, the ability of an insurer to do simple arithmetic, so that I do not have to.

Just hoping.