REPORT: Access Denied: How Utilization Management Protocols Can Block Access to Life-Saving Treatments

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You can find the full report here: Access Denied: How Utilization Management Protocols Can Block Access to Life-Saving Treatments.

 

Americans who purchase health insurance are facing mounting hurdles from five specific “utilization management” (UM) techniques that can prevent access to essential care when insurers employ them too aggressively, according to a new report from the Doctor-Patient Rights Project (DPRP).

“Insurers may have legitimate reasons to ‘manage’ utilization as a response to rising healthcare costs,” noted Seth Ginsberg, Co-Founder and President of Global Healthy Living Foundation, a Founding Member of DPRP, “but cost-saving methods often go too far, and block patients from accessing treatments or procedures their doctors conclude are critical to their health.”

The report, Access Denied: How Utilization Management Protocols Can Block Access to Life-Saving Treatments, identified five UM methods most commonly responsible for blocking patient access to care:

 

  • Overly Burdensome Prior Authorization Requirements.

The majority of doctors report facing difficulty getting insurance providers to authorize about one-quarter of their prescription requests, which can delay patients from receiving necessary care.

  • Overly Restrictive Step Therapy Programs.

Many insurers require patients to try a series of cheaper, alternative treatments before agreeing to cover the one prescribed by the patient’s doctor, which can delay effective care in some cases, and introduce adverse drug reactions in others.

  • Overly Expansive Formulary Exclusions.

In the past three years, CVS’s list of treatments excluded from its formulary more than doubled, while Express Scripts’ list grew by 77 percent. These exclusions can deny many patients coverage for effective treatments they may have been taking for years.

  • Overly Aggressive Non-Medical Switching.

Insurers change their formulary tiers to reduce coverage for some treatments—often in the middle of a coverage year— forcing some patients to switch to cheaper medications that may be less effective.

  • Overly Inclusive Adverse Tiering.

By placing all or most of the medications used to treat a particular illness on formulary tiers that require the highest patient co-pays, many insurers can discourage certain patient groups from enrolling in their health plans.

 

The DPRP report suggests that these methods may not be effective strategies for limiting healthcare expenses when insurers apply them too aggressively. When applied to patients with chronic diseases, for example, some utilization management methods can prevent early treatment or may discourage patients from continuing treatment that has proven effective. As a result, a disease may develop more quickly than otherwise, which can increase the lifetime cost of a patient’s care.

“In our 2017 survey of insured Americans, DPRP found that many people fear that insurance providers have effectively become the arbiters of patient care,” noted Dr. Theresa Rohr-Kirchgraber, Past President of the American Medical Women’s Association (AMWA) and a Founding Member of DPRP. “Our analysis of how insurers are employing many of these utilization management methods suggests these patients are justified in feeling that their physician is no longer the primary voice driving treatment decisions.” she said.

Not What the Doctor Ordered: Barriers to Healthcare Access for Patient, our report on its 2017 survey of insured Americans about their access to medications, tests, and medical procedures, can be downloaded here.