Curb restrictive utilization management practices


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 mitigating the impact of restrictive utilization management on patients.

Insurers and health plans employ utilization management 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, utilization management strategies cost the U.S. health care system an estimated $93.7 billion, forcing patients to shoulder nearly $36 billion in cost-sharing.

“Fail-first” policies or the need to navigate excessive administrative hurdles can delay or undermine a prescribed treatment plan. Medication utilization management such as step therapy, requiring a patient to try a payer-preferred drug before proceeding with their originally prescribed regimen, and prior authorizations, requiring patients or providers to secure pre-approval before receiving coverage for a prescription drug, can adversely impact patients. These practices can disrupt care delivery and negatively impact clinical outcomes.

Mid-year insurance plan changes are also another utilization management technique that 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.

For patients with chronic and rare diseases, specialty medications offer significant treatment advances, reduce the risk of disease progression, and improve survival rates. In most cases, a generic or less expensive alternative is not available for their condition.

Cost-sharing for specialty medications—which can be as high as 50 percent of the drug’s cost—increase the chance patients will delay starting therapy, skip prescription refills, and interrupt or abandon treatment. Placing a sizeable financial responsibility for specialty medications on patients creates an environment where the most economically vulnerable people have the least access to innovative therapies.