Prior Auth, Utilization Management Can Have Unintended Consequences, PBMI Panel Says

The tools of prescription drug utilization management — step therapy and prior authorization—can help guarantee that the right patients get the right treatments, while controlling costs. But these methods are being exploited beyond their original intent, and some patients suffer needlessly, according to panelists taking part in the 4th Annual Pharmacy Benefit Management Institute (PBMI) Specialty Pharmacy Rx Forum.

Sharon (Frazee) Phares, Ph.D., M.P.H., senior vice president for research and data innovation, Pharmaceutical Strategies Group (PSG); Renee Rayburg, vice president of specialty clinical consulting, Artemetrx, PSG; and Ted Okon, MBA, executive director of the Community Oncology Alliance (COA),joined Jonathan Ogurchak, Pharm.D., CSP, CEO and co-founder of STACK, for a discussion centered on a recent white paper from Phares and Rayburg titled, “Should All Drugs Be Treated Equally When It Comes to Utilization Management?”

Sharon Phares

The white paper, which was supported by Genentech, argues that utilization management can be helpful when used appropriately. But when applied to the complex cases seen in specialty pharmacy, the results feel more like a war of attrition with patients and their doctors worn down by delays or denials.

Both the paper and the discussion focused on prior authorization for multiple sclerosis (MS rheumatoid arthritis treatments and in oncology, where delays in getting necessary drugs can result in disease progression — or worse.

Renee Rayburg

Okon and COA have been outspoken about a policy change that has allowed step therapy in Medicare Advantage, which he calls “fail first.” In recent years, discussions COA’s annual meeting have escalated when angry oncologists have described patients developing brain metastases while they waited for an insurer to approve a therapy.

In their white paper, Phares and Rayburg described a “time equals brain,” referring to evidence that delays in treatment for patients with multiple sclerosis could result in more significant disability, including accelerated loss of brain volume.

The panelists described cases of patients being forced to take drugs they knew wouldn’t work and then having to pay another co-pay when the drug they needed in the first place is approved. Employers should listen to complaints their employees have about prior authorization, they said.

Ted Okun

Okon said that in many cases, utilization practices aren’t being used to steer patients to take the most cost-effective drug but, rather, to one that will mean the largest rebate for the PBM — even if that means a higher price for the employer and higher out-of-pocket costs for the employee. The recent spate of mergers of between insurers and PBMs will accelerate the trend, Okon said.

"It’s because they've made a deal,” he said. “When an insurer/PBM literally extorts money from a manufacturer to basically use that drug — if it's the most profitable drug, not the least expensive drug — then that's the problem.”

Okon said that during the COVID-19 pandemic it has been especially frustrating when treatment decisions made by oncologists to reduce trips to infusion centers have been overruled or delayed.

Employee and physician complaints about utilization management experiences add up, the panelists said. Phares said that when employers sponsor a benefit plan, it’s a “double whammy” when employees pay premiums and then have bad experience getting prescribed drugs.

“You have to remember that as an employer, you’re not only providing member benefits for your employees. They’re your coworkers,” she said.

Phares said that physician practices spend, on average, about 14.6 hours a week on prior authorization issues. The white paper reports that health plan executives view prior authorization as successful way for holding down costs. In contrast, according to December 2017 by the American Medical Association, more than 90% of physicians reported that prior authorization had a negative effect on patient clinical outcomes.

Clinical consequences are being documented. As Rayburg discussed during the panel discussion, a real-world evidence study published last year in JAMA Neurology showed that early, intensive disease-modifying therapy for people with MS produced better long-term outcome than using disease-modifying therapy of moderate efficacy and changing therapy when symptoms worsened.

Jonathan Ogurchak

Ogurchak noted that when chronic conditions and cancer are managed with specialty drugs there’s an additional challenge of some employers switching health plans, and a drug that was effective for some employees might not be on the formulary of the company’s new health plan.

“Now you need to move from [one] formulary criteria to [a new] formulary criteria,” he said. “It presents a challenge, particularly if you're not getting the appropriate baseline data that you might be looking at. … What happens when you're an RA (rheumatoid arthritis) patient that's starting on a disease-modifying therapy, and you are improving, or if you're a cancer patient and now your margins are much better?”