Curb restrictive utilization management practices

PAN’S POSITION

Avoid disruptions in care by curbing restrictive utilization management practices.

Congress, along with public and private insurers, should take action to minimize disruptions in care by reducing and streamlining practices that delay needed treatment for patients.   

Insurers and health plans use certain strategies—including step therapy, prior authorizations, mid-year plan changes, and placement of drugs on specialty medication tiers—to reduce payer spending. Despite their intended purpose, according to Health Affairs utilization management strategies cost the U.S. health care system an estimated $93.3 billion, forcing patients to shoulder nearly $36 billion in cost-sharing. 

“Fail-first” policies, also known as step therapy, require a patient to try a payer-preferred drug before proceeding with their originally prescribed regimen. Prior authorizations require patients or providers to secure pre-approval before receiving coverage for a prescription drug. These practices can disrupt care delivery and negatively impact clinical outcomes for patients. 

Mid-year insurance plan changes can threaten the stability of patient care. These unexpected switches can subject patients to new formulary changes, increased cost-sharing obligations, and other utilization review requirements without warning. 

Cost-sharing for specialty medications increases the chance patients will delay starting therapy, skip prescription refills, or interrupt or abandon treatment altogether. In fact, according to a study published in the Journal of Managed Care & Specialty Pharmacy, increasing cost sharing above $100 was associated with up a 32-75 percent abandonment rate for certain specialty drugs.  

I was trying to take care of my health and a panel who knows nothing about me or my health was making decisions about my care. It’s very disheartening. It shouldn’t be this way.”

– Karen, a patient living with multiple sclerosis, on her experience with step therapy