The Cost of Delay is $93 Billion

Not only do utilization management policies like step therapy (or “fail first”) and prior authorization delay patient care and discredit medical specialists’ expertise, experience and extensive training, they also carry a steep financial cost.

There’s well-documented findings that “fail first” policies force patients to go through months of ineffective treatment with second or third choice medications before the more expensive drug therapy – the one their doctor originally prescribed – is finally covered. Patient copayments/cost sharing accompany these many rounds of filled prescriptions and subsequent follow-up treatment visits.

Health Affairs recently published a study that “estimates that payers, manufacturers, physicians, and patients together incur approximately $93.3 billion in costs annually on implementing, contesting, and navigating utilization management.” This includes $26.7 billion in physician time spent crisscrossing the utilization management administrative labyrinth – time could have otherwise been spent on direct patient care. On top of that, patients spend approximately $35.8 billion annually in drug cost sharing for failed therapies. That is a staggering amount. Just think, those dollars could have been used for enhancing patient quality of life, providing respite to family caregivers or modifying a patient’s home with an accommodation like a wheelchair ramp.

Study authors, Scott Howell, Perry T. Yin, and James C. Robinson, conclude that all stakeholders “would benefit from a de-escalation of utilization management…”

Patient and Providers United echoes this call to preserve timely access to the medication, procedures and care recommended in comprehensive treatment plans physicians tailor for each patient.