Not Just a Cost-Containment Tool: Utilization Management Should Benefit Patients

December 15, 2022
piggy bank and calculator

Key Takeaways From Our 2022 Utilization Management Summit

On Dec. 1, we hosted a virtual forum to gather stakeholders interested in the role that utilization management plays in our healthcare system. Utilization management (or UM for short) is a set of techniques used to reduce or contain healthcare costs. Our forum focused on what we as patients, caregivers, and advocates can do to create a more patient-centered system. The main message was this: By working together, we can help ensure UM is used appropriately to benefit patients and not used strictly as cost-containment tools.

Our forum speakers all brought important perspectives to the conversation. They acknowledged that there is still a lot of work to be done, but we are stronger together and should be encouraged by the action we have seen. Our speakers included:

  • Congressman Larry Bucshon, M.D., Cynthia Cox of Kaiser Family Foundation
  • Greg Gierer of the Better Medicare Alliance
  • Sara van Geertruyden of the Partnership for Improving Patient Care (PIPC)
  • Rachel Klein of The AIDS Institute
  • Sarah Buchanan of the National Psoriasis Foundation
  • Bonnie Duffy of the MAPRx coalition 

“[We] aren’t necessarily against the use of utilization management, we are just trying to make sure that the system works so that there can be a dialogue between patients, providers, and their health plans.”

— Sarah Buchanan

Watch our Utilization Management Summit now.

Forum Highlights

During the forum, which was split into 2 panels, we looked back at UM advocacy efforts and the evolution of several UM tools. We also looked ahead to challenges in 2023, but also opportunities for engagement.

Summing up the first panel, Sara highlighted 2 things we need to focus on:

  • more evidence that helps us understand what works for who and when
  • that payers respond to the evidence by making sure people are getting what they need

High-deductible health plans: Cynthia shared data on the current state of high-deductible health plans and why employers find these types of plans appealing. Cynthia asked the audience to ponder a fantastic question: “If the main reason we’re spending so much money on healthcare in the U.S. is prices more so than utilization, then what should we be thinking about as alternative approaches, rather than just continuing to raise deductibles?”

Read More: What Is a High-Deductible Health Plan?

Pharmacy benefit managers & prior authorization: Greg addressed the role pharmacy benefit managers play in delaying patient care. He also discussed the interests of Congress and the Administration to reduce the burden of current, outdated prior authorization processes, and the need to modernize and expedite the process. He highlighted the importance of modernizing prior authorization processes so that they “preserve the clinical value of the tool, but make it work in such a way that patients have access to all medically necessary and clinically appropriate care.”

Quality Adjusted Life Year: Sara discussed the discriminatory nature of Quality Adjusted Life Year, a method used to calculate value, and the failure to incorporate what truly matters to patients. To calculate a QALY, you must assign value to a person’s life. Seniors, chronically ill patients, and people with disabilities receive assigned values that are lower than young, healthy individuals. “It could lead policymakers and payers to conclude that treatments for seniors, patients with chronic conditions, or people with disabilities are not worth covering,” Sara said.

Improving Seniors’ Timely Access to Care Act: Dr. Bucshon, a former cardiothoracic surgeon, discussed the Improving Seniors’ Timely Access to Care Act. This is a bipartisan bill he coauthored to eliminate the problematic delays associated with prior authorization in Medicare Advantage. Dr. Bucshon said it’s his personal mission “to champion patient-centered healthcare reforms that empower individuals and their doctors to make healthcare decisions.” A focal point of his legislative work is recognizing that “patients and providers must have freedom to decide which is the best treatment or approach in a particular situation."

“When misunderstood or misused, prior authorization can delay or restrict needed medical intervention and result in administrative burdens for providers, and, as you may know, the misuse is occurring.”

— Larry Bucshon, M.D.

Rachel summed up the second panel of our summit: “It’s really important just to remind policymakers at all levels — state, federal, and local — that at the end of the day, all of this is about whether or not people who need healthcare are able to get it.”

Copay accumulator adjuster programs: Rachel shared information about copay accumulator adjuster programs, which present a burden to patients. With these programs, any copay assistance the patient receives is not counted toward a patient’s deductible or out-of-pocket maximum. This means that, when the assistance runs outs, patients are left to pay the full out-of-pocket cost for their drugs. Often, they cannot afford this. The HELP Copays Act was introduced to address this problem by ensuring any payment paid “by or on behalf of” the patient is counted toward their deductible and out-of-pocket maximum.

Step therapy: Sarah shared the negative implications of step therapy (also referred to as “Fail First or “Try and Fail”) for patients who must fail on a drug, or multiple drugs, first before their insurance covers the drug that was originally prescribed. Step therapy “results in a delay in access to care that can be avoided,” Sarah noted.

Currently, many state bills have been passed to address this problem. This demonstrates that policymakers understand the urgent need for policy solutions to help patients receive care in a timely manner. However, state bills vary and cover different groups than the federal bill. Passing the Safe Step Act at the federal level is important to ensure that there is a medically reasonable and efficient process for step therapy exceptions.

Read More: What Is Step Therapy?

The Inflation Reduction Act: Bonnie concluded our panelist presentations with an overview of priorities for advocates to pay attention to during the implementation of the Inflation Reduction Act. The act is designed to make healthcare more accessible, equitable, and affordable for people with Medicare.   

These priorities include:

  • Medicare Part D reforms
  • the framework for Medicare drug price negotiations
  • Medicare Part D rebates

During subregulatory guidance periods, stakeholders can share their thoughts during short periods for comment. “It is not enough to implement the law, but the important work, as CMS implements these really large changes, are going to make a real mark on whether the new law has its intended effects,” Bonnie said.

CSC’s policy and advocacy team will be monitoring these opportunities for comment and will share more information when it is available.

What Can You Do?

It is important to bring to light the burdens that UM practices can have on patients when used as a cost-containment tool. Here are some ways you can help raise awareness about these concerns:

  1. Write to your legislators.
  2. Share your story about how UM tools have delayed your care.
  3. Request a meeting with your members of congress in-district, at your state capitol, or in Washington, D.C.

 Questions about advocacy opportunities? Contact us