Policy and Regulation News

Utilization Management Delays Cancer Care, Diminishes Outcomes

One in three patients report experiencing delays in their cancer care due to utilization management techniques.

Utilization management delays cancer care, diminishes outcomes

Source: Thinkstock

By Jessica Kent

- Utilization management (UM) requirements are likely delaying cancer care and resulting in poorer outcomes for cancer patients, according to a survey conducted by Public Opinion Strategies and Hart Research Associates on behalf of the American Cancer Society Cancer Action Network (ACS CAN).

Thirty-four percent of cancer patients and caregivers have experienced delays in their own or their loved one’s care waiting on approval from their health insurance plan for a treatment, test, or prescription drug. Additionally, 56 percent of oncologists frequently have to wait on the patient’s plan to approve a cancer treatment, test, or prescription medication.

Researchers surveyed more than 400 patients, caregivers, and providers to explore how existing utilization management techniques impact cancer patients and providers.

Younger cancer patients and caregivers were more likely to report experiencing delays in cancer care. Nearly 60 percent of those between the ages of 18 and 44 had experienced delays due to utilization requirements. In comparison, just 28 percent of individuals ages 45 to 64 and 17 percent of those over 65 experienced the same.

The survey also revealed that providers are encountering delays in care as well. Forty-three percent of providers said their patients are unable to afford the prescription drugs needed for their cancer treatment or side effects because of the latter’s coverage.

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“These findings clearly show utilization management is negatively impacting cancer care. Delayed treatment can have life-threatening consequences, especially for cancer patients, and is exactly why Medicare’s six protected classes were created in the first place,” said Lisa Lacasse, president of ACS CAN. “Patients need to have timely access to the best and most appropriate drugs to treat their disease.”

The survey also asked respondents about four different UM techniques that health plans could use regarding prescription drug coverage of cancer medication.

Researchers found that 96 percent of physicians are subject to prior authorization requirements with their cancer patients’ health plans; 54 percent of patients and caregivers, similarly.

Ninety percent of physicians reported that health plans have required generic substitutions of prescription medications while 44 percent of caregivers and patients said their health plans have done the same.

Eighty-nine percent of physicians — as well as 41 percent of caregivers and patients — also observed that plans have put limitations on the total amount of prescription medicine that can be administered at one time.

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While 28 percent of caregivers and patients said their health plans required them to try lower-cost medications before higher-cost medications, nearly 90 percent of physicians had experienced this phenomenon.

Younger patients and caregivers were more likely to have experienced these UM requirements than patients and caregivers over 65. Over half of respondents ages 18 to 44 had experienced three of the four UM requirements included in the survey.

Cancer patients and caregivers with private insurance were also more likely to have experienced these UM requirements than those with Medicare. Fifty-two percent of privately insured patients have experienced one or two of the four requirements while 47 percent of Medicare patients reported the same.

When asked how UM techniques are affecting their practice of medicine, seven in ten physicians believe these requirements have a negative impact on care delivery. Nearly 90 percent contend that requirements are negatively affecting administrative tasks and paperwork, and 79 percent claim that they are impeding physician decision-making regarding patient care.

UM techniques are negatively impacting care for cancer patients, according to physicians. Eighty-three percent reported that the requirements affect the ability of patients to have timely access to medications and treatments, and 76 percent said it negatively impacts the quality of care patients receive.

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Survey participants also don’t believe these requirements should be included in health plans.

“There is a majority of opposition among cancer patients, caregivers, and physicians for each of the UM techniques we tested being adopted and used by health plans,” researchers said. “Pluralities to majorities of physicians, cancer patients and caregivers believe if these UM techniques were part of all health plans, it would negatively impact the treatment cancer patients receive.”

Over 70 percent of physicians and 60 percent of patients and caregivers believe that trying lower-cost medications would have negative effects on patient care. Eighty-one percent of physicians believe prior authorization would have negative effects, and over half of patients and caregivers said the same.  

As cancer treatments continue to evolve and improve, it will be critical to eliminate barriers to care access.

“Targeted cancer therapies with no clinical equivalent are coming onto the market with increasing frequency, but they won’t do any good if patient access is delayed, which could threaten the effectiveness of the therapy itself,” Lacasse concluded.

“Patients need to be heard on this critical issue. We call on Congress to deliver a strong message to the administration to withdraw these proposed changes.”