Utilization Management Policies Research Articles

Medicaid managed care restrictions on medications for the treatment of opioid use disorder.

To examine whether Medicaid managed care plan (MCP) utilization management policies for buprenorphine-naloxone and injectable naltrexone are related to key state Medicaid program policy decisions. We abstracted data on state Medicaid regulatory and policy information from publicly available sources and publicly available insurance benefit documentation from all 241 Medicaid MCPs operating in 2021. In this cross-sectional study, we used bivariate and multivariate analyses to examine whether Medicaid MCP prior authorization and quantity limits on receipt of buprenorphine and injectable naltrexone were associated with key state Medicaid choices to leverage federal funds to expand coverage and eligibility (Medicaid expansion, 1115 waivers) and to regulate Medicaid MCPs (uniform preferred drug lists, medical loss ratio remittance). Models were adjusted for MCP characteristics, including profit status, behavioral health contracting arrangement, National Committee for Quality Assurance accreditation, size, market share, and state opioid overdose death rates. Average marginal effects (AME) were reported. Utilization management was common among MCPs, and restrictions were more commonly applied to buprenorphine than injectable naltrexone, despite its higher cost. States that required MCPs to comply with utilization management policies stipulated in a uniform preferred drug list were more likely to require prior authorization for buprenorphine (AME: 0.29, 95% CI: 0.15-0.42) and injectable naltrexone (AME: 0.25, 95% CI: 0.12-0.38). MCPs in states that required plans to pay back earnings above a certain threshold were less likely to require prior authorization for buprenorphine (AME: -0.30, 95% CI: -0.43 to -0.18). Restrictions on medications for opioid use disorder are widespread among MCPs and vary by medication. State Medicaid regulatory and policy characteristics were strongly linked to MCPs' utilization management approaches. State Medicaid policy and contracting approaches may be levers to eliminate utilization management restrictions on medications for opioid use disorder.

Emergency Admissions and the Prescribing of Buprenorphine, Methadone, and Psychotropic Medications in People with Sickle Cell Disease: An Analysis of National Insurance Claims

Background Although there have been efforts to address overdose risks and treatment gaps in general populations receiving opioids, there is has been little research examining potential drug-related poisoning risks in some of the highest-need and complex populations, including those with sickle cell disease (SCD). Chronic opioid medications are necessary and well-tolerated for the treatment of chronic pain, diffuse inflammation, chronic organ damage, and vaso-occlusive pain crises for people with SCD. Previous studies have found that patients with SCD are not more likely to develop addiction to opioids than the general population. However, amid the ongoing endemic of drug-related poisonings in the U.S., epidemiological data is scarce regarding the clinical characteristics of people who have SCD and physiologic opioid tolerance and dependence. There has been particularly limited work on the intersection of sociodemographic characteristics, substance use, and other mental health conditions in the SCD population. Concern has also been raised about the ongoing opioid epidemic contributing to increased stigma, and greater barriers to the management of acute and chronic pain in SCD. Studies have shown that preoccupation with opioid prescription monitoring hindered the ability of physicians to provide comprehensive SCD care. People with SCD often face more restrictive utilization management policies for opioids than peers with other forms of chronic pain (i.e., cancer-related pain). In order for us to develop better interventions for people with SCD, real-world data is urgently needed to describe the current treatment landscape and identify gaps in care for people with SCD and physiologic opioid dependence or tolerance. Using administrative claims data in the US, we aim to: 1) quantify the burden of hospitalization and emergency room admission for medication-related poisoning events, 2) describe the prevalence of opioid prescriptions, such as buprenorphine and methadone, in people with SCD and physiologic opioid dependence or misuse. Methods In this retrospective cohort study of people with physiologic opioid dependence or opioid use disorder (OUD), we analyzed ten years (1/2006-12/2016) of data from the Merative™ MarketScan® Commercial and Multi-State Medicaid Databases. The predictor variable was SCD (versus a comparator group of people with chronic pain) with diagnoses identified using ICD-9/10 codes. The outcome variables were 1) emergency admissions or hospitalization for non-fatal drug/medication-related poisoning events during enrollment, and 2) prescriptions for buprenorphine, methadone, and other opioids, identified via procedure codes and linked pharmacy records respectively. We used multivariable cox regression to estimate the relationship between SCD diagnosis and time until poisoning events. Multivariable poisson regression models were used to assess the relationship between SCD and buprenorphine, methadone, and other opioid prescriptions. Results Our overall cohort consisted of 25,448 people with ICD9-10 opioid dependence or misuse, including 313 with SCD and 25,135 with non-SCD chronic pain. In the SCD cohort, the median age was 30.8 years, and 82% were enrolled in Medicaid. Compared to the non-SCD chronic pain cohort, the SCD cohort had more hospitalizations or emergency admission for iatrogenic events (37.4% vs 9.8%, aHR=2.21[2.12-2.31]). With regards to medication receipt compared to peers with non-SCD chronic pain, the SCD cohort had a lower prevalence of buprenorphine prescriptions (8% vs 30.1%, aRR=0.20[0.18-0.21]) and a higher prevalence of methadone prescriptions for chronic pain (63.6% vs 6.8%, aRR=5.36[5.21-5.51]) and non-methadone/non-buprenorphine opioid prescriptions (80.5% vs 33.7%, aRR=2.20[2.15-2.25]). Conclusions We observed an elevated rate of emergency admission and/or hospitalization for drug/medication-related poisoning, as well as a significant burden of psychiatric comorbidity in a cohort of people with SCD and physiologic opioid dependence or OUD. The prescribing of potentially safer opioids, such as buprenorphine, was uncommon in the cohort. Further research is urgently needed to optimize opioid treatment strategies, combat stigma, and improve the comprehensive management of pain and co-occurring disorders in the SCD population.

Changes in Medicaid Fee-for-Service Benefit Design for Substance Use Disorder Treatment During the Opioid Crisis, 2014 to 2021

Medicaid is the largest payer of substance use disorder treatment in the US and plays a key role in responding to the opioid epidemic. However, as recently as 2017, many state Medicaid programs still did not cover the full continuum of clinically recommended care. To determine whether state Medicaid fee-for-service (FFS) programs have expanded coverage and loosened restrictions on access to substance use disorder treatment in recent years. In 2014, 2017, and 2021, a survey on coverage for substance use disorder treatment was conducted among state Medicaid programs and the District of Columbia with FFS programs. This survey was completed by Medicaid program directors or knowledgeable staff. Data analysis was performed in 2022. The following were calculated for a variety of substance use disorder treatment services (individual and group outpatient, intensive outpatient, short-term and long-term residential, recovery support, inpatient treatment and detoxification, and outpatient detoxification) and medications (methadone, oral and injectable naltrexone, and buprenorphine): (1) the percentage of Medicaid FFS programs covering these services and medications and (2) the percentage of Medicaid FFS programs using utilization management policies, such as copayments, prior authorizations, and annual maximums. This study had response rates of 92% in 2014 and 2017 (47 of 51 states) and 90% in 2021 (46 of 51 states). For the 2021 wave, data are reported for the 38 non-managed care organization plan-only states. Between 2017 and 2021, coverage of individual and group outpatient treatment increased to 100% of states, and use of annual maximums for medications decreased to 3% or less (n ≤ 1). However, important gaps in coverage persisted, particularly for more intensive services: 10% of Medicaid FFS programs (n = 4) did not cover intensive outpatient treatment, 13% (n = 5) did not cover short-term residential care, and 33% (n = 13) did not cover long-term residential care. Use of utilization controls, such as copays, prior authorizations, and annual maximums, decreased but continued to be widespread. In this survey study of state Medicaid FFS programs, increases in coverage and decreases in use of utilization management policies over time were observed for substance use disorder treatment and medications. However, these findings suggest that some states still lag behind and impose barriers to treatment. Future research should work to identify the long-term ramifications of these barriers for patients.

Utilization Management in the Medicare Part D Program and Prescription Drug Utilization.

Medicare Part D has significantly enhanced access to prescription drugs among Medicare beneficiaries. However, the recent rapid rise of utilization management policies in the Medicare Part D program may have adversely affected access to prescription drugs. I study the effects of expected and observed exposure to utilization management in prescription drug utilization using Medicare Part D claims data from 2009 to 2016 and an instrumental variables strategy based on the interaction of lagged health status and the set of plans available to each beneficiary. I find that the expected share of spending subject to utilization management increases the observed share, with the smallest effect for prior authorization. Increases in the expected share of drug spending subject to prior authorization increases Part D spending by $122.27 per percentage point, with almost three-quarters of this increase being paid by the Medicare program, rather than beneficiaries or plans. Comparable increases in step therapy and quantity limit exposure increase spending by $46 and decrease spending by $31, respectively. Interestingly, increased exposure to prior authorization and quantity limits increases the average price per 30-day prescription.

Physician perceptions of drug utilization management: Results of a national survey.

The use of drug utilization management techniques such as formulary exclusions, prior authorizations, and step edits has risen sharply during the last decade, contributing to the growing burden on physicians and patients. Limited quantitative data exist, however, on physician perceptions of drug utilization management. A national survey was conducted between February 9 and March 30, 2021, targeting office-based physicians working in the United States to assess their perceptions on drug utilization management in their practice. Of the 742 physicians that participated in the study, over 80% reported deciding against prescribing certain treatments in anticipation of drug utilization management at least sometimes (>50% of the time). Despite utilization management having an impact on prescribing decisions, about half of physicians said that the utilization management policies they encounter rarely or never (0–25% of the time) align with clinical evidence.

Effects of utilization management on health outcomes: evidence from urinary tract infections and community-acquired pneumonia

ABSTRACT Background Utilization management policies are pervasive in the Medicare Part D program. We assess the effect of utilization management restrictions in the Medicare Part D program on the quality of care in two clinical areas – community-acquired pneumonia (CAP) and urinary tract infections (UTI). Methods In this study, we identified new cases of CAP and UTI from Medicare claims data from 2010 to 2016. We assessed the relationship between exposure to utilization management for antibiotic medications suitable for treating these conditions and adverse health outcomes, based on the Agency for Healthcare Research and Quality prevention quality indicators. Results We identified 147,526 cases of CAP and 632,407 UTI cases in our data. In these samples, the adverse event rate varied from 3.6 to 5.7%. The probability of an adverse event increased by 0.75 (p = 0.061) percentage points for each ten percentage point increase in exposure to quantity limits (one form of utilization management) among people with CAP. There was no relationship between utilization management and adverse events in the UTI cohort. Conclusions In some circumstances, exposure to utilization management policies–particularly quantity limits–may adversely affect health.

Association of opioid utilization management with prescribing and overdose.

Deaths from prescription opioids have reached epidemic levels in the United States, yet little is known about how insurers' coverage policies may affect rates of fatal and nonfatal overdose among individuals filling an opioid prescription. Retrospective cohort study using 2010-2016 Medicare claims data for beneficiaries with 1 or more filled prescriptions for a Schedule II opioid. Outcomes were opioid volume dispensed in morphine milligram equivalents (MME), number of days supplied, and number of pills dispensed on each prescription and emergency department or inpatient stay associated with an opioid overdose during a prescription or within 7 days of the end of the prescription. A total of 7.03 million prescriptions for Schedule II opioids were dispensed over 1.87 million Part D beneficiary-years. The 7.03 million opioid prescriptions were associated with 8.5 opioid overdoses per 10,000 prescriptions. Prior authorization was associated with larger opioid volumes per prescription (103.6 MME; 95% CI, 36.2-171.0). Step therapy was associated with a greater number of days supplied (0.62 days; 95% CI, 0.10-1.13) and more pills dispensed (6.12 pills; 95% CI, 2.17-10.1). Quantity limits were associated with smaller opioid volumes (24.3 MME; 95% CI, 12.3-36.3) and fewer pills dispensed (2.35 pills; 95% CI, 1.77-2.93). In adjusted models, beneficiaries filling an opioid requiring prior authorization experienced 3.3 fewer overdoses per 10,000 prescriptions (95% CI, 0.41-6.2). Opioid utilization management among these beneficiaries was associated with mixed effects on opioid prescribing, and prior authorization was associated with a decreased likelihood of subsequent overdose. Further work exploring the impact of utilization management and insurer policies is needed.

Schizophrenia population health management: perspectives of and lessons learned from population health decision makers.

BACKGROUND: Despite therapeutic advances for patients with schizophrenia, improving patient outcomes and reducing the cost of care continue to challenge formulary decision makers. OBJECTIVES: To (1) understand the perspectives of formulary decision makers on challenges to optimal schizophrenia population management and (2) identify best practices and recommendations for mitigating these challenges. METHODS: This mixed-methods study, conducted in a double-blind manner, comprised in-depth telephone interviews with formulary decision makers from February through May 2020, and a web-based follow-on survey that was sent to all participants in October 2020. US-based formulary decision makers were recruited if they were directly involved in schizophrenia drug formulary or coverage decision making for national or regional payers, health systems, or behavioral health centers. Formulary decision makers' perceptions of challenges, policies, and programs related to schizophrenia population health management were assessed generally and in the context of the COVID-19 pandemic. RESULTS: 19 formulary decision makers participated in the interviews and 18 (95%) completed the survey. Participants reported a spectrum of patient- and payer-driven challenges in schizophrenia population health management, including medication nonadherence, high pharmacy and medical costs, and frequent hospitalizations and emergency department visits. Participants noted that COVID-19 had worsened all identified challenges, although patient unemployment (mean score of 2.00 on a scale of 1 [made much worse] to 5 [made much better]) and reduced access to psychiatric care (mean score, 2.12) were most negatively affected. The most common strategies implemented in order to improve schizophrenia population health management included case management (89%), telemedicine (83%), care coordination programs (72%), strategies to mitigate barriers to accessing medication (61%), and providing nonmedical services to address social determinants of health (56%). Participants noted that, ideally, all treatments for schizophrenia would be available on their formularies without utilization management policies in place in order to increase accessibility to medication, but cost to the health plans made that difficult. Whereas 61% of respondents believed that long-acting injectable antipsychotics (LAIs) were currently underused in their organizations, only 28% represented organizations with open access policies for LAIs. Participants believed that among patients with schizophrenia, LAIs were most beneficial for those with a history of poor or uncertain adherence to oral medications (mean score of 4.50 on a scale of 1 [not at all beneficial] to 5 [extremely beneficial]) and those with recurring emergency department visits and inpatient stays (mean score, 3.94). Study participants reported slightly increased use of LAIs (mean score of 3.17 on a scale of 1 [negatively impacted] to 5 [positively impacted]) among their patients with schizophrenia in response to the COVID-19 pandemic; 29% of participants reported easing access restrictions for LAIs. CONCLUSIONS: Participants described persisting challenges and various approaches intended to improve schizophrenia population health management. They also recommended strategies to optimize future health management for this population, including expanding programs to address social determinants of health and mitigating barriers to accessing treatment. DISCLOSURES: This study was funded by Janssen Scientific Affairs, LLC. Roach, Graf, Pednekar, and Chou are employees of PRECISIONheor, which received financial support from Janssen Scientific Affairs, LLC, to conduct this study. Chou owns equity in Precision Medicine Group, the parent company of PRECISIONheor. Lin and Benson are employees of Janssen Scientific Affairs, LLC. Doshi has served as a consultant, advisory board member, or both, for Acadia, Allergan, Boehringer Ingelheim, Janssen, Merck, Otsuka, and Sage Therapeutics and has received research funding from AbbVie, Biogen, Humana, Janssen, Novartis, Merck, Pfizer, PhRMA, Regeneron, Sanofi, and Valeant.

Removal of prior authorization for medication-assisted treatment: impact on opioid use and policy implications in a Medicare Advantage population.

BACKGROUND: More than 30% of Medicare beneficiaries and 40% of patients dually eligible for Medicare and Medicaid use opioids. With an estimated 8%-12% of patients developing an opioid use disorder (OUD) after initiating opioids, opioid misuse is a significant public health challenge, especially among high-risk Medicare populations. Medication-assisted treatment (MAT) is the use of medications for the treatment of OUD and to prevent relapse to opioid use. MAT is the most effective treatment for OUD. There are a variety of barriers to MAT therapy that may delay access to treatment. OBJECTIVE: To study the impact of the removal of prior authorization requirements for MAT medications on MAT utilization, opioid utilization, and clinical outcomes, including emergency department visits, inpatient admission, relapse rates, behavioral health services, and nonopioid pain medication utilization, among opioid-using individuals with Medicare Advantage Prescription Drug (MAPD) coverage. METHODS: This retrospective, cross-sectional study used administrative medical, pharmacy, and enrollment data to identify chronic opioid users and a subset cohort initiating MAT use in 2017, when prior authorization requirements were in effect, and 2018 after removal of prior authorization requirements. Opioid and MAT utilization and clinical outcomes from emergency department visits were also examined before and after prior authorization requirements. A logistic regression analysis was conducted to examine the impact of the policy change on relapse rates, comparing relapse rates in 2017 and 2018, after controlling for potentially confounding demographic and clinical factors. RESULTS: This policy change was followed by a decrease in opioid utilization, an increase in MAT initiation, and a 4% decline in relapse rates. Patients initiating MAT after removal of prior authorizations had a 19% decrease in likelihood of relapse, and those with an OUD diagnosis were 47% less likely to relapse. The majority of MAT recipients were aged younger than 65 years, had a mental or behavioral health disorder diagnosis, and initially used relatively low doses (< 90 MME) of prescription opioids. There were no statistically significant differences in the use of behavioral health services or the use of nonopioid medications from 2017 to 2018. CONCLUSIONS: Utilization management policies should ensure appropriate MAT use, while minimizing impediments to access. Providing patients with evidence-based therapy effective for the treatment of OUD is essential to patient recovery and combating the consequences of the opioid epidemic. Further strides are needed to eliminate additional obstacles to OUD care. DISCLOSURES: No outside funding supported this study. All authors are or were employees of Humana, Inc., at the time of the study and have no other potential conflicts of interest to disclose.

Cornerstones of ‘fair’ drug coverage: appropriate cost sharing and utilization management policies for pharmaceuticals

At the heart of all health insurance programs lies ethical tension between maximizing the freedom of patients and clinicians to tailor care for the individual and the need to make healthcare affordable. Nowhere is this tension more fiercely debated than in benefit design and coverage policy for pharmaceuticals. This paper focuses on three areas over which there is the most controversy about how to judge whether drug coverage is appropriate: cost-sharing provisions, clinical eligibility criteria, and economic-step therapy andrequired switching. In each of these domains we present 'ethical goals for access' followed by a series of 'fair design criteria' that can be used by stakeholders to drive more transparent and accountable drug coverage.

Impact of drug utilization management policy on prescription opioid use in Georgia Medicaid.

To examine the effectiveness of changes in opioid prescription policies on opioid prescribing and health services utilization rates in Georgia Medicaid. This study used data from the Georgia Medicaid patient enrollment, medical and pharmacy claims database from 2009 to 2014.We performed an interrupted time series analysis to examine the effect of the policy changes. Outcome measures assessed the trends in the indicators of potential inappropriate prescribing practices, including overlapping prescriptions of opioid + opioid, opioid + benzodiazepine and opioids + buprenorphine/naloxone, as well as health services utilization, including hospitalization, mean length of stay, outpatient office and emergency room visits. A total of 712 342 opioid users aged 18-64 were included in the study. The policies were associated with significant decreasing trend of opioid + opioid (-0.0011; 95% CI = -0.0020, -0.0002) and opioid + benzodiazepines (-0.001; 95% CI = -0.0022, -0.0006) overlapping while associated with a significant immediate decrease in and opioids + buprenorphine/naloxone after the implementations (-0.0014; 95% CI = -0.0025, -0.0003). Significant immediate decrease in level of office visits and ER visits were seen with the policy implementation (office visit: -0.2939; 95% CI = -0.5528, -0.0350, ER visit: -0.0740, 95% CI = -0.1294, -0.0185). The policies were not shown to be significantly associated with hospitalization and the mean length of inpatient stay. Our analysis suggests that Georgia Medicaid opioid policies were useful to contain inappropriate opioid use.

Prevalence of Utilization Management Policies Among the Psoriatic Disease Community: Results From the 2019 National Psoriasis Foundation Advocacy Survey

Introduction: Utilization management (UM) policies are becoming more common among commercial insurance policies. However, little research has been conducted to understand the prevalence of experiencing UM restrictions among patients with psoriatic disease. Objectives: To understand the prevalence of UM policies within the psoriatic patient community and examine their relationship with patient characteristics. Methods: An online survey of 1205 individuals with a psoriatic disease from the National Psoriasis Foundation’s constituent database was conducted. Data were collected from July 7 to July 31, 2019. The main outcomes of interest for the present study were frequency of experiencing UM policies (eg, prior authorization [PA] or step therapy [ST]) from their insurance company, number, and type of UM policies experienced and relationship between patient characteristics and experiencing these policies. Results: Survey respondents reported high rates of experiencing some form of UM restriction (80.5%). Nearly half (45.1%) of the survey respondents indicated their insurer required them to try a therapy other than the therapy originally prescribed by their physician, a practice known as ST or “fail first” and 73% of respondents reported having to receive PA from their insurer before initiating treatment. Conclusions: Individuals with psoriatic disease commonly encounter UM policies from their insurer when attempting to manage their disease. Statistical analyses suggest that UM policies are related to the type of treatment used by patients and the type of psoriatic disease.

Impact of utilization management policy on uptake of hypofractionated radiation in early-stage breast cancer.

7015 Background: While hypofractionated radiation (HFR) after breast-conserving surgery is a cost-effective, patient-centered treatment in early-stage breast cancer (ESBC), less than 40% of eligible women received it in 2013. In 2016, a large commercial payer implemented a utilization management policy to encourage HFR for eligible women through denying reimbursement for extended-course radiation. We assessed the impact of the policy on HFR use and associated spending. Methods: We conducted a retrospective, adjusted difference-in-differences analysis using administrative claims of women continuously enrolled in 14 geographically diverse commercial health plans covering 6.9% of US adult women. The study population included women aged 18 or older with ESBC who were eligible for HFR according to 2011 guidelines from the American Society for Radiation Oncology. Women who received mastectomy, brachytherapy, or &lt; 11 or &gt; 40 external beam fractions were excluded. We compared HFR use and associated spending between women in fully-insured and Medicare Advantage (fully-insured) plans for whom the policy applied vs. self-insured or Medicare supplemental insurance (self-insured) plans for whom the policy did not apply. We adjusted for age, comorbidity, region, Medicare enrollment, and prior chemotherapy. Results: Among 10,540 eligible women, 3,619 (34%) were in fully insured plans and thus subject to the policy. There were no meaningful differences in mean age (63.8 vs. 65.0), Charlson comorbidity index (3.0 vs. 3.2), or practice setting between the fully-insured and self-insured groups. The policy was associated with an increase in HFR (4.2 adjusted percentage point difference-in-difference [ppd], 95% CI 0.0 to 8.4, p = 0.051) and a non-significant decrease in radiotherapy-associated expenditures (-$2,275, p = 0.09). Spillover analyses revealed significantly higher uptake of HFR among self-insured patients who were indirectly exposed to the policy through seeing the providers who also treated fulled insured women (8.5 adjusted ppd, 95% CI 3.6 to 13.5, p = 0.001), compared to those who were not exposed. Conclusions: A payer’s utilization management policy was associated with direct and spillover increases in HFR use, even after accounting for a strong secular trend towards increased hypofractionation use. However, policymakers must balance the impact of this and similar policies against their additional administrative costs.

Association of Utilization Management Policy With Uptake of Hypofractionated Radiotherapy Among Patients With Early-Stage Breast Cancer

Breast cancer accounts for the largest portion of cancer-related spending in the United States. Although hypofractionated radiotherapy after breast-conserving surgery is a cost-effective and convenient treatment strategy for patients with early-stage breast cancer, less than 40% of eligible women received hypofractionated radiotherapy in 2013. To assess the association of a large commercial payer's utilization management policy with the use of hypofractionated radiotherapy among women with early-stage breast cancer and its associated cost. A retrospective, adjusted difference-in-differences economic analysis was conducted using administrative claims data from January 1, 2012, to June 1, 2018, of women 18 years or older with early-stage breast cancer who were eligible for hypofractionated radiotherapy according to 2011 guidelines from the American Society for Radiation Oncology and were continuously enrolled in 14 geographically diverse commercial health plans covering 6.9% of US adult women. Women who received mastectomy, brachytherapy, or less than 11 or more than 40 external beam fractions of radiotherapy were excluded. A utilization management policy was used to encourage the use of hypofractionated radiotherapy among women in fully insured and Medicare Advantage (fully insured) plans. Under the new policy, claims for extended-course radiotherapy were not reimbursed for fully insured women who were eligible for hypofractionated radiotherapy. This policy did not apply to women in self-insured or Medicare supplemental insurance (self-insured) plans, allowing these groups to serve as a comparison group. The primary outcome was use of hypofractionated radiotherapy, and the secondary outcome was the cost of this type of radiotherapy. Of 10 540 eligible women, 3619 (34.3%) were in fully insured plans and thus subject to the policy. There were no meaningful differences between the fully insured and self-insured groups in mean (SD) age at the start of radiotherapy (63.8 [8.6] vs 65.0 [8.9] years), mean (SD) Charlson Comorbidity Index score (3.0 [1.5] vs 3.2 [1.6]), or practice setting (outpatient hospital setting, 2982 of 3619 [82.4%] vs 5600 of 6921 [80.9%]). The policy was associated with an increase in use of hypofractionated radiotherapy among fully insured patients subject to the policy (adjusted percentage point difference-in-difference, 4.2%; 95% CI, 0.0%-8.4%; P = .05) and a nonsignificant decrease in radiotherapy-associated expenditures (-$2275 relative to self-insured patients; P = .09). Spillover analyses revealed a significantly higher uptake of hypofractionated radiotherapy among self-insured patients who were indirectly exposed to the policy (adjusted percentage point difference-in-difference, 8.5%; 95% CI, 3.6%-13.5%; P < .001) compared with those who were not exposed. This study suggests that a payer's utilization management policy was associated with direct and spillover increases in the use of hypofractionated radiotherapy, even after accounting for a long-term secular trend in the uptake of hypofractionated radiotherapy in the control groups. Utilization management may promote evidence-based cancer care.

Evaluating a Utilization Management Policy in Radiation Oncology

Evaluating a Utilization Management Policy in Radiation Oncology

Cost-effectiveness of diabetes treatment sequences to inform step therapy policies.

Cost-effectiveness estimates are useful to a health plan when they are specific to a utilization management policy question. To help inform a step therapy policy decision, this study assessed the 3-year cost-effectiveness of adding a sodium-glucose cotransporter 2 (SGLT2) inhibitor versus switching to a glucagon-like peptide-1 receptor agonist (GLP-1 RA) in patients with type 2 diabetes who are on metformin and a dipeptidyl peptidase-4 (DPP-4) inhibitor from both private and public payer perspectives in the United States. Cost-effectiveness analysis. A decision-analytic model was built incorporating goal glycated hemoglobin (A1C) achievement as the effectiveness measure, as well as adverse effect and discontinuation rates from clinical trial data. One-way, scenario, and probabilistic sensitivity analyses were performed. In a cohort of 1000 patients, adding an SGLT2 inhibitor led to $3.9 million more in spending and 93 more patients reaching goal A1C compared with switching from a DPP-4 inhibitor to a GLP-1 RA. This resulted in an incremental cost-effectiveness ratio (ICER) of $42,125per patient to achieve goal A1C from the private payer perspective. Using a public payer perspective led to an ICER of $103,829. These results were most sensitive to changes in drug costs and the proportion of patients achieving A1C goal or discontinuing. Assuming a $50,000 willingness-to-pay threshold, adding an SGLT2 inhibitor was cost-effective compared with switching from a DPP-4 inhibitor to a GLP-1 RA from a private payer perspective but not from a public payer perspective. This study highlights how differences in payer reimbursement rates for medications can lead to contrasting results.

A Primer for Managed Care Residents: How to Conduct Research Using Live Medical and Pharmacy Claims Data.

Managed care organizations are growing more sophisticated in their ability to analyze data. There are increasing numbers of data analysts at managed care organizations, as well as more types of real-time, or "live," data available. These data range from pharmacy claims and enrollment files to medical claims, medical records, and linkages to external data. Moreover, the data are often curated in a way that allows for easier data analysis. Using these data, managed care residents are often required to perform a project to evaluate a utilization management policy or clinical program. Yet, there is a lack of guidance specific to managed care organizations on how to conduct such a research study using "live" claims data. This Viewpoint article provides a primer for managed care residents and other managed care professionals who are seeking to use data to help inform decisions on how to manage their beneficiaries' health and costs. DISCLOSURES: There was no funding source for this manuscript. Hung reports a grant from the Agency for Healthcare Research and Quality and personal fees from Blue Cross Blue Shield Association, outside the submitted work. Gedey, Groeneweg, and Jay have nothing to disclose.

Using a Budget Impact Model Framework to Evaluate Antidiabetic Formulary Changes and Utilization Management Tools.

Traditional budget impact models predict the financial consequences of a new drug entering the market. This study provides an example of applying the budget impact framework to a new research question of interest to managed care organizations-what is the budget impact of our formulary and utilization management (UM) policy changes? To predict the 3-year annual budgetary impact of TRICARE's antidiabetic formulary and UM policy changes using TRICARE claims data. A budget impact model was built in Microsoft Excel using health plan claims data for a 3-year time horizon. Model outcomes included spending on antidiabetic medications and medications used for side effect treatment. In sensitivity analyses, medical costs from inpatient, outpatient, and emergency room visits were also estimated. Model inputs included health plan antidiabetic medication utilization, as well as publicly available drug cost, rebate, dispensing fee, and patient cost-sharing estimates. Type of enrollee and pharmacy were also incorporated into the model. Sensitivity analyses varied estimates for utilization switch rates between preferred and nonpreferred agents, drug costs, rebates, and dispensing fees, as well as predicted impact from implementation delays. For the 623,827 affected by the formulary and UM policy changes, the model predicted annual savings that increased from $24 million in the first year to $43 million in the third year after the changes. The majority of savings came from drug acquisition costs, as opposed to rebates, copays, and dispensing fees. Sensitivity analyses found savings across all varied parameters and scenarios except an unlikely scenario when 0% of utilization switched from nonpreferred to preferred agents. The model also predicted that the formulary and UM policy changes would lead to $529,439 in savings from medical visit costs in Year 3. This budget impact model predicted cost savings from the payer's formulary and UM policy changes. This project was supported by grant number F32HS024857 from the Agency for Healthcare Research and Quality (AHRQ), which contracted with the University of Maryland School of Pharmacy to conduct this study. The content is solely the responsibility of the authors and does not necessarily represent the official views of the AHRQ, which had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or design to submit the manuscript for publication. The findings discussed in this manuscript represent the views of the authors and do not necessarily reflect the views of the Department of Defense, the Defense Health Agency, nor the Departments of the Army, Navy, and Air Force. Hung reports a grant from the AHRQ, during the conduct of the study, and personal fees from CVS Health and BlueCross BlueShield Association, outside the submitted work. Mullins reports grants and personal fees from Bayer and Pfizer and personal fees from Boehringer-Ingelheim, Janssen/J&J, Regeneron, and Sanofi, outside the submitted work. Mullins, Slejko, and Shaya are employed by the University of Maryland School of Pharmacy. Haines and Lugo have nothing to disclose. Part of this content was previously presented as a poster at the 2017 AMCP Managed Care & Specialty Pharmacy Annual Meeting; March 27-30, 2017; Denver, CO, and as poster and oral presentations at the 2017 AMCP Nexus Meeting; October 16-19, 2017; Dallas, TX. Part of this content was published as Hung's PhD dissertation.

Understanding Utilization Management Policy: How to Manage This Increasingly Complex Environment in Collaboration and With Better Data.

As innovation in cancer care continues and newer costly therapies receive approval, utilization management will continue to grow as an important way that payers can attempt to control costs and value while providing service to their patients. Although utilization management may be necessary, it takes many forms and is optimized when it ensures appropriate patient access to services and minimizes administrative burdens of physicians and staff. These opportunities are best explored in collaboration with payers. Information systems today provide an excellent platform for data sharing to facilitate collaborative efforts between care delivery organizations and payers to optimize these efforts. As state and national policies differ regarding utilization management, it is important for clinicians to be both aware and involved.

CARDIOVASCULAR RISK IN PATIENTS DENIED ACCESS TO PCSK9I THERAPY

Proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9is) significantly reduce LDL-C for patients uncontrolled with statin and/or ezetimibe. Payers restrict access to PCSK9is using stringent utilization management (UM) policies leading to high rejection rates. We describe acute