A study recently published in PLOS ONE found that drug utilization management impacts physician treatment decisions and can lead to additional resource use by patients. According to the study, the use of drug utilization management techniques, including formulary exclusions, prior authorizations, and step edits, has sharply risen over the past few years, resulting in an increased burden on physicians and patients.
The study noted that the three largest pharmacy benefit managers expanded their formulary exclusions from 109 drugs in 2014 to 846 drugs in 2020. Additionally, 1/3 of large commercial payers impose utilization management on specialty drugs that are stricter than those on the Food and Drug Administration’s (FDA’s) label.
To that end, a national survey was conducted between February 9 and March 30, 2021, assessing perceptions of drug utilization management in their practice of office-based physicians in the United States. 742 physicians participated in the study. The survey did not focus on quantifying the costs incurred by physician practices, but instead focused on the perception and overall impact of drug utilization management on physician practices.
On average, participant physicians reported handling 155 drug prescriptions for their patients per week. Prior authorizations and formulary restrictions were reported to impact roughly one in five prescriptions on average, and were more common than step edits and other or unknown types of drug utilization management. Overall, physicians reported weekly average volumes of 23.5 formulary restrictions, 19.7 prior authorizations, 12.6 step edits, and 7.9 other types of drug utilization management.
Additionally, drug utilization management resulted in longer patient visits 2/3 of the time, additional patient visits about half the time, and additional lab tests or imaging more than half the time. Two-thirds of physicians reported that they spent extra time working, 30% reported spending less time on other administrative tasks, 16% scheduled fewer patient visits, and rescheduled patient visits 12% of the time.
More than 80% of the participating physicians reported deciding against prescribing certain treatments in anticipation of drug utilization management at least half of the time. However, despite utilization management having an impact on prescribing decisions, about half of the participating physicians said that the utilization management policies they encounter rarely align with clinical evidence.
When it comes to the types of evidence that physicians believe should be used to inform drug utilization management, 66.6% prioritized medical society guidelines, 62.8% said clinical trial data, 55.0% said real-world outcomes evidence, 31.1% referenced the FDA label, and 11.9% preferred payer’s discretion.
The study also noted that with the wide range of types of practices and corresponding physician experiences with utilization management, future research should consider whether differences in practice types (such as how many other physicians are in the office or whether they are affiliated with a larger health system) and physician characteristics (such as their age or level of experience) impacts physicians’ perceptions of drug utilization management.
The study concluded that as the prevalence of drug utilization management continues to grow, the impact on physician treatment decisions – and patients – will continue to be an important topic.
“This study makes it clear – payer and PBM decision-makers are too often an invisible third person in the exam room, influencing medical decisions. The utilization management tools used by health plans need close scrutiny to ensure they’re not barriers to good outcomes for patients,” said John O’Brien, President and CEO, National Pharmaceutical Council.