Factors that increase utilization management risk: a proof of concept

Area of Science:

• Health Services Research
• Pharmaceutical Policy
• Patient Outcomes

Background:

• Utilization management (UM) policies by payers significantly impact patient access to treatments.
• Quantifying the patient risk associated with UM policies is crucial for evaluating healthcare access.
• Existing metrics do not adequately capture the patient-centric risk of UM implementation.

Purpose of the Study:

• To develop a quantitative metric, the Data-Based Utilization Management Risk Designation (BURDEN) score, to assess patient risk from UM policies.
• To evaluate the association between the BURDEN score and real-world UM practices of healthcare payers.

Main Methods:

• A targeted literature review and expert elicitation were used to develop the BURDEN score, incorporating 9 patient-outcome-focused UM factors.
• The BURDEN score was weighted based on input from 6 stakeholders.
• Real-world data analysis, including ordinary least squares regression, examined the relationship between the BURDEN score and payer coverage policies.

Main Results:

• The BURDEN score identified UM policies for myasthenia gravis, multiple myeloma, and lupus nephritis as posing the highest patient risk.
• Treatments with higher BURDEN scores were associated with a 22.0% decreased likelihood of any UM restriction and a 36.2% decreased likelihood of step edits by payers.
• Statistical significance was observed for these associations (P=.041 and P=.039, respectively).

Conclusions:

• The study successfully developed the BURDEN score, a novel quantitative measure for patient risk associated with UM policies.
• Payers demonstrated a modest responsiveness to treatments identified as high-risk by the BURDEN score.
• Coverage decisions were not consistently patient-centered, as evidenced by increased UM use for some high-BURDEN treatments.