Many of our patients have unpleasant experiences navigating the complex world of drug utilization management. This includes determining which formulary level the drug will be at, whether there are any prior authorization requirements, and our co-payment. The burden also falls on doctors, because they need to prove why a given patient needs a specific drug to ensure coverage. Pharmaceutical companies also need to pay for programs that help patients and doctors understand usage management plans, rebates, free samples, and co-payment assistance. The payer also needs to pay the additional cost of managing these utilization management procedures. The fact that utilization management imposes costs on various stakeholders is not surprising. In fact, the goal is to impose costs on different stakeholders to incentivize the use of low-cost drugs. However, an unresolved question is how large these costs actually are.
A sort of Recent papers Health affairs Authors: Howell, Yin and Robinson, Found that the annual cost in the United States is 93.3 billion U.S. dollars. Patients bear the largest burden at 35.8 billion U.S. dollars. Doctors (26.7 billion U.S. dollars) and manufacturers (24.8 billion U.S. dollars) rank second and third respectively. The payer’s cost is much smaller, but not trivial, at $6 billion.
The author draws these conclusions through a literature review of peer-reviewed studies published between 2009 and 2020, supplemented by other news articles.
The author believes that one solution to the use of management arms races is for manufacturers to price drugs based on therapeutic value in exchange for PBM/payers to allow “value-based access” while minimizing utilization management restrictions. Although reasonable, determining the appropriate concept of “value” is often challenging. However, removing barriers to patient access is a laudable goal.
