Five utilization management techniques that health insurers use to control costs can block access to essential care for some patients, according to a new report.
The report (PDF) from the Doctor-Patient Rights Project—a nonprofit coalition of doctors, patients, caregivers and advocates—identified five legitimate tactics, such as prior authorization, that when used too aggressively create barriers to patient care.
“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, co-founder and president of Global Healthy Living Foundation, a founding member of the project that is working to ensure doctors and patients drive care decisions, said in an announcement.
The report pinpointed the following five utilization management methods that can block access for patients who purchase insurance:
1. Overly burdensome prior authorization requirements. A majority of doctors report difficulty getting insurance providers to authorize about one-fourth of their prescription requests, which can delay patients from receiving necessary care.
2. Overly restrictive step therapy programs. Many insurers require patients to try cheaper, alternative treatments before agreeing to cover the one prescribed by the patient’s doctor. This can delay effective care and cause adverse drug reactions.
3. Overly expansive formulary exclusions, which can deny patients coverage for treatments they may have been taking for years. As examples, the report said in the past three years, CVS’ list of treatments excluded from its formulary more than doubled and Express Scripts’ list grew by 77%.
4. Overly aggressive non-medical switching. This occurs when insurers change their formulary tiers to reduce coverage for some treatments, forcing patients to switch to less expensive medications that may be less effective.
5. Overly inclusive adverse tiering. In this case, insurers place all of most of the medications used to treat a particular illness on formulary tiers with the highest patient co-pays. This tactic can discourage certain patient groups from enrolling in an insurer’s health plans.
The report said when used too aggressively, the strategies may in fact increase healthcare expenses. For instance, patients with chronic diseases may not get early treatment or may be discouraged from continuing an effective treatment because of costs. That can increase the lifetime cost of a patient’s care.