Many of us who are patients have the unpleasant experience of navigating the complex world of drug utilization management. This includes determining what tier of the formulary a drug will be in, if there are prior authorization requirements, and what our copay will be. The burden is also on physicians, as they must justify why specific medications are needed for a given patient to be covered. Pharmaceutical companies also have costs for programs that help patients and physicians navigate utilization management programs, reimbursements, free samples, and co-payment assistance. Payers also have the additional cost of administering these utilization management programs. The fact that utilization management imposes costs on a variety of stakeholders is not surprising. In fact, the goal is to impose costs on different stakeholders to incentivize the use of lower-cost drugs. However, an unanswered question is how big these costs really are.
A. recent article in Health matters by Howell, Yin and Robinson, finds that the annual cost in the US is $ 93.3 billion. Patients bear the biggest burden at $ 35.8 billion, with physicians ($ 26.7 billion) and manufacturers ($ 24.8 billion) ranking second and third. The cost to payers is much lower, but not trivial, at $ 6.0 billion.
The authors reach this conclusion by conducting a literature review of peer-reviewed studies published between 2009 and 2020 supplemented by other news articles.
The authors argue that a solution to the utilization management arms race would be for manufacturers to price drugs based on the value of treatment in exchange for PBM / payers to allow “value-based access” with restrictions. utilization management minimums. While sensitive, identifying an appropriate notion of “value” is often challenging. However, removing barriers to patient access is a laudable goal.