Payer group disputes report that utilization management blocks essential care access

A coctor writing a prescription
AHIP says health plans are working with doctors to provide patient care. (Getty/18percentgrey)

Editor's note: This article has been updated to include comments from The Doctor-Patient Rights Project.

A national health insurance company trade group is refuting a report that says some utilization management techniques, such as prior authorization, can block access to essential care for some patients. 

“Insurers may have legitimate reasons to ‘manage’ utilization as a response to rising healthcare costs, but cost-saving methods often go too far, and block patients from accessing treatments or procedures their doctors conclude are critical to their health,” Seth Ginsberg, a founding member of the The Doctor-Patient Rights Project, said in an announcement about the report last week.

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But America’s Health Insurance Plans (AHIP) said health plans are collaborating more than ever before with providers in order to ensure that patients get the care they need while reducing unnecessary tests and procedures. It also claims the group, the nonprofit Doctor-Patient Rights Project, is backed by the pharmaceutical industry.

“This coalition is very clearly a Big Pharma-initiated campaign, attempting to distract from skyrocketing drug pricing,” Cathryn Donaldson, AHIP’s director of communications, said in an email to FierceHealthcare. Donaldson said the coalition targets health plans and would have insurers pay for medications without question, review or approval.

The Doctor-Patient Rights Project is funded by Aimed Alliance, which "seeks to improve healthcare in the United States through access to evidence-based treatments and technologies," according to its site; Global Healthy Living Foundation, a patient advocacy group; and pharmaceutical company Amgen.

When it comes to prior authorizations and step therapy, two of the utilization methods cited in the report, Donaldson said health plans are collaborating more than ever with providers to deliver better healthcare.

RELATED: Groups press insurers to reform prior authorization

“Medical management processes and tools, such as prior authorization or step therapy, are designed to support approaches to care that are most effective. This ensures that patients receive the safest, most-effective care at the most affordable cost,” she said.

As for formulary exclusions and what the report called “nonmedical switching,” Donaldson said health plans routinely evaluate their formularies from a clinical standpoint to ensure they are balancing access for patients with safe, evidence-based and affordable care.

“If AHIP believes that utilization management techniques are not being aggressively applied by its members to deny access to care as indicated in our report, they are welcome to share the denial rates associated with these practices to bring greater transparency to this process," Ginsberg, president and co-founder of the Global Health Living Foundation and a founding member of the Doctor Patient Rights Project, said in an email to FierceHealthcare.

He also said the organization is fighting to restore the fundamental practice of medicine and to ensure doctors, in partnership with their patients, drive care decisions. "We would be more than happy to work with AHIP to help achieve that mission,” he said.