Carole Florman, policy fellow at CancerCare, talks about how utilization management can have unintended consequences for patients.
Employers don’t have a full understanding of how utilization management can create barriers for patients to access prescription drugs. In a survey by CancerCare, a national cancer support organization, the large employers surveyed said costs were the primary reason for implementing these measures.
Nearly all of the survey respondents (94%) said that employer organizational healthcare costs are more influential than any other factor when making health benefit decisions, including employee costs and issues. They overwhelmingly (98%) said that direct costs are the most important information source in their benefits decision making.
But many said utilization management was not a barrier to access cancer-related healthcare. Of those surveyed, 62% said formulary tiers do not impact patient access to cancer care. Additionally, 55% said step therapy and 43% said prior authorizations don’t impact patient access.
Utilization management has unintended consequences, said Carole Florman, policy fellow at CancerCare.
“Because of out-of-pocket costs or prior authorization, many prescriptions get abandoned at the pharmacy counter,” she said in an interview. “What that tells me is that the system isn't working right. I don't believe that that is the intention of any employer offering a benefit package. But unfortunately, the design of the programs often leads to that result.”
Costs are one of the biggest reasons patients report not take taking medications as prescribed. Three in 10 patients (29%) surveyed last year by the Kaiser Family Foundation report not taking their medicines as prescribed at some point in the past year because of the cost. Additionally, one in six surveyed said that they haven’t filled a prescription (16%), and 13% said they have cut their pills in half or skipped a dose of a prescribed medicine due to cost.
Prior authorization can lead to delay in care, physicians report in a 2021 survey by the American Medical Association. Of those surveyed, 55% said that prior authorization sometimes leads to patients to abandon their treatment and 34% said that prior authorization has led a serious adverse event.
While step therapy may seem completely benign, Florman said, there can be instances where this can cause serious delays for patients.
A 2019 survey by Xcenda found that patients who experienced step therapy were more likely to be nonadherent or pay out of their own pocket for a medication. Additionally, 40% of step-therapy patients stopped taking medicines that did not help, 29% stopped taking medicines due to cost, and 27% stopped taking medicines because the insurance company did not pay for the medicines taken. Xcenda surveyed patients, physicians, pharmacists, and payers.
Florman said there could be some guardrails around utilization management that, while helping to hold down costs, don’t limit access to drugs. For example, it should be used around non-serious illnesses or conditions. And, if it’s used, there should have very strict guard rails around it.
“It's about making sure that we are solving a problem that's solvable with a utilization management technique, and then limiting the management to that area,” she said. “It's making sure that the formulary is designed in a reasonable way.”
CancerCare has developed a toolkit geared toward employers to help develop benefit plans with the patient in mind.
Florman says developing benefits with employees in mind is a nuanced discussion.
“We're not advocating that all utilization management should just go away,” Florman said. “We understand that the economics in the prescription drugs space just don't allow for all medications to be free. But we do believe that with care and by asking the right questions and putting the right requirements into benefit plan and summary documents, that employers can really do a lot to both help their bottom line while they're helping their employees.”