Health plans often experiment with different models to identify optimal strategies on utilization management, especially high-cost prescription drugs. In its new policy statement, the American Society of Clinical Oncology (ASCO) has raised concerns that these strategies could reduce patient access.
Prior authorization (PA), clinical pathways, step-therapy protocols, restrictive formularies, and specialty tiers are some of the ways in which health insurance companies restrict use of prescription drugs. Such restrictions can prove problematic for patients being treated for cancer, because often there is a lack of interchangeable clinical options in oncology. Ensuring compliance with the different health plan policies is also a huge administrative investment for clinics, and to avoid this, ASCO, in collaboration with the American Medical Association, developed resource utilization principles to bring about reform with the process.
“Utilization management strategies, when implemented without appropriate patient safeguards, can impede patient access to high-value, clinically appropriate care,” said ASCO President Daniel F. Hayes, MD, FASCO, FACP. “Payer policies must reflect the current requirements of contemporary cancer care and be evidence-based on what constitutes high-quality care.”
The new policy statement provides the following recommendations:
- PA policies must be streamlined to avoid unnecessary barriers, delays in care, and other administrative burdens. ASCO recommends that payers standardize their PA procedures to alleviate administrative burdens on the clinical teams. Other recommendations include consulting with oncologists, an efficient appeals process, and integrating the PA process into electronic health records for authorization at the point of care.
- Utilization management policies must protect patient access to medically appropriate care. ASCO believes that step therapy, specialty tiers, restrictive formularies, and non-parity of patient cost sharing for oral cancer drugs, can restrict patient access to clinically appropriate, individualized care.
- Step Therapy. Cost of a drug often defines a “preferred” therapy and the “fail-first” approach, which, according to the policy statement, may not be appropriate in cancer care due to the absence of many interchangeable options. This could compromise patient care.
- Specialty-Specific Tiers. Specialty tiers can impose on the patients cost share for a prescription drug. ASCO recommends that “the cost-sharing burdens imposed on individuals who require access to anti-cancer drug regimens should not exceed the cost-sharing requirements that otherwise exist under a health insurer’s medical benefit.”
- Restrictive Formularies. ASCO would like to see transparency with the formulary-development procedure followed by health plans, “and specialty clinical oversight to ensure mechanisms for how inclusion is valued is clear and medically appropriate.”
- Lack of Parity for Oral Chemotherapy. Oral parity continues to be a topic of contention, wherein oral chemotherapy agents, covered under the pharmacy benefit, have bigger cost-sharing requirements compared with intravenous drugs administered at the clinic and covered under medical benefit. ASCO recommends that “patient copayments, coinsurance, deductibles and other limits for oral anticancer drugs should be reasonable and should be no less favorable for cancer patients than would occur under the policies governing intravenous and injected anticancer drugs."
- High-quality clinical pathways provide an appropriate utilization management strategy for cancer drug treatments when adequate patient safeguards exist. ASCO believes that clinical pathways reduce variability and can be a powerful tool to deliver high-value care. Pathways are also fair-balanced, if up-to-date, in that they do not compromise a patient’s clinical needs if evidence points to using high-cost drugs, including going “off-pathway” if needed without the need for PA. However, the number of clinical pathways has ballooned in recent years, which, in addition to creating practice management difficulties, significantly raises their administrative burden as well.
The policy statment recommends following ASCO’s criteria, “which promote patient protections for clinical pathway development, implementation and use, and analytics.”