Healthcare Business News

Exchange plans pose more prescription-use barriers

By Darius Tahir
Posted: March 24, 2014 - 7:15 pm ET

(This article has been updated with a correction.)

Patients covered by exchange-based insurance are more likely than those in employer-sponsored plans to face utilization management controls—such as prior authorization and step therapy—in filling their prescriptions, a report Monday from healthcare consultancy Avalere Health contends.

In the mental health category, 50% of drugs were covered without utilization management in employer-sponsored plans versus 15% in exchange-based plans, according to Avalere's data. Also, 27% of oncology drugs were covered without utilization management in employer-sponsored plans, compared with 16% in exchange-based plans. The majority of HIV/AIDS drugs—60%—were covered free of utilization management in exchange-based plans, but that number still paled in comparison to patients with employer-sponsored insurance.

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Insulins also rated quite highly, with just more than 40% being free of utilization management for patients covered by exchange-based plans; drugs for multiple sclerosis were particularly low, at approximately 5%.

The analysis examined drugs in 21 drug classes and spotlighted three—mental health, oncology and HIV/AIDS. It examined formularies from bronze- and silver-rated plans in the 15 largest states. It compared the utilization controls to controls in a sample of employer-sponsored insurance plans and found that patients in exchange-based plans had more barriers.

While the rationale for utilization management is to reduce costs faced by insurers—hence reducing costs passed on to consumers—the risk is that it might also affect health. “The utilization management tools we profiled are not as widely used in commercial insurance settings, so they need to be closely monitored for their effects on consumers and on the clinicians responsible for their administration,” Avalere Executive Vice President Matt Eyles said in the report.

Caroline Pearson, the group's vice president, said in an interview that we “don't have good evidence” as to the clinical effects in patients. “We know that high rates (of utilization management) reduce use,” she said, but it wasn't necessarily clear how that affected patient health. What was really unusual—and needed watching—was the extent of the management.

Unlike other management regimes, patients might find it particularly difficult to substitute to lower-cost pharmaceuticals—which might negatively impact health were prescriptions to go totally unfilled. The differential for mental health drugs was particularly worth monitoring, Pearson stated.

For providers, she continued, effects would be varied. Oncologists often have the administrative capacities to deal with such difficulties and delays; a psychologist in a small practice might not have the resources.

The trends in the healthcare market point toward further use of utilization management, meaning that extensive use of such tools might jump from exchange-based plans to the broader pool of employer-sponsored insurance as they face continued pricing pressures, Pearson said.

But the trend might provoke complaints from patient advocacy groups, she said. There might be “less resistance” were patients given the ability to switch to roughly clinically equivalent drugs, she said. Ultimately, she said, the success or failure of the gambit rests on patients' ability to “find a way to navigate” this new system.

(This article has been updated to correct Caroline Pearson's name.)

Darius Tahir is a Washington, D.C.-based freelancer for Modern Healthcare.

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