Utilization Management in Oncology: Current Strategies and a Path Forward

While utilization management in general is a pain point for everyone, it’s a necessary evil in the United States, where we spend 18% of our gross domestic product on healthcare, explained Debra Patt, MD, MPH, MBA, vice president, policy and strategy, Texas Oncology; medical director, analytics, McKesson Specialty Health, during a session at the 2018 American Society of Clinical Oncology (ASCO) Annual Meeting in Chicago, Illinois.

“We have real problems in our house of medicine, and they’re worse in oncology than they are in other places because we’ve been ripe with innovation, and a lot of that is tied to very expensive drugs,” she added.

There is a myriad of strategies used to control the cost of oncology drugs including: prior authorization, step therapy, drug quantity supply limitations, member cost sharing, closed specialty pharmacy networks, formulary tiering, and adjusted drug reimbursement to lower expenditures.

Patt highlighted step therapy, which is particularly common among commercial insurers. In 2014, nearly 75% of large employers reported offering employee plans that use step therapy. While, inherently, it makes sense to lower cost by utilizing lower cost therapies prior to higher cost therapies, there’s a concern in oncology that preferring some drugs over others in a step therapy strategy can have a negative impact on patients by not getting the optimal drug first, she explained.

In response to these concerns, many states have passed laws against step therapy and against fail-first therapy, stating that commercial insurers in that state cannot participate in such programs.

Patt then discussed the use of prior authorization, its importance, and its consequences.

“When I started in oncology practice 12 years ago, I would write a chemotherapy [prescription], and if we had the drug, the patient could be treated the same day; and if we didn’t have the drug, the patient could be treated the next day,” she said. “Now, I set the expectation to all my patients that there is just no way, in the absence of [an] emergency, that they’re going to get their drug within a week.”

Patt recognized that when prior authorizations are denied, it is likely because the therapy is considered experimental, not compliant with guidelines, or there isn’t adequate supporting evidence. In these cases, prior authorization serves as a deterrent for having less than guideline-based care.

However, she noted that there is a lack of transparency on what will lead to a successful authorization and it’s often a significant administrative burden.

In regard to patient cost sharing, she noted that when patients have a higher stake in or have to pay more for their healthcare, they utilize it more efficiently, and that holds true with therapies as well.

The last utilization management strategy she highlighted were formularies. “In general, we don’t think they are a great strategy to get patients their optimal treatment,” said Patt. “However, I think there probably are some scenarios where they’re very useful.” She gave the example of a state Medicaid program that has a certain budget, where formulary drugs can be utilized to stay within the budget.

Patt ended her session by discussing a path forward. “As we think about utilization management in general, I do think there is a better solution,” she said. “In general, I think that because oncology decision making is sophisticated, the decision tree by which you make decisions has to be populated by many data elements. It’s not a blunt instrument, it’s a much more sophisticated tool.”

She urged for collaboration and investing in information solutions to provide the right information for approval early on. Instead of having an administrator calling to go through the process of prior authorization, using a support system embedded in the electronic health record can automatically move toward prior authorization.

“When I’m in clinic and I see a patient with stage 2 breast cancer and I enter in all their information, I come up with a set of choices of therapy through the decision support system embedded in my health record that gives me appropriate pathways,” Patt explained. She argued that the same should happen when going through prior authorization. “We can use the information system in and of itself to communicate that information and make our machines work for us.”