Access to prescribed medications and treatments should be grounded in proven clinical judgment, timely care and patient-centered decision making. However, many health plans and pharmacy benefit managers rely on utilization management tools that increase administrative burden, delay care and undermine the clinician-patient relationship. These tactics can have real consequences for patients and clinicians, impacting adherence, health outcomes and overall quality of care.
Below is a breakdown of the three most common utilization management practices and how they impede access to proper care.
With prior authorization, patients must get their insurers’ approval before accessing a clinician-prescribed medication, procedure or test. Patients can wait days or even weeks for approval while symptoms worsen or their disease progresses. Meanwhile, clinicians and their staff spend countless hours completing forms, gathering documentation and navigating opaque insurer requirements. Even when approvals are ultimately granted, the delay itself can be harmful.
Step therapy, often called “fail first,” requires patients to try one or more insurer-preferred treatments before accessing the treatment their clinician prescribed. While step therapy may have cost-management intentions, rigid implementation can undermine individualized treatment plans. Patients may be forced to use less effective treatments or endure unnecessary side effects before accessing the medication their clinician determines is best. This can delay effective care and jeopardize health outcomes.
Non-medical switching occurs when an insurer changes a patient’s medication—typically to a less costly alternative for the insurer—even if that patient is already stable on his or her current treatment. These switches are driven by formulary changes, tier moves or pricing incentives unrelated to a patient’s clinical needs. For patients who have achieved stability, being forced onto a different medication (sometimes with different efficacy or side-effects) can disrupt progress and increase the risk of adverse reactions.
