Unbiased Analysis of Today's Healthcare Issues
When we think of utilization management (e.g., prior authorizations, step edits), we often think payers only use these for higher cost branded products including biologics. Generic drugs should have low cost sharing and limited utilization management. One question, however, is whether payers’ utilization management practices for biosimilars mirror those of biologic products, or small-molecule generics,…
A CMS proposed rule would expedite the prior authorization approval process. CMS summarizes key provisions of the rule as follows: Proposals include requiring implementation of a Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) standard Application Programming Interface (API) to support electronic prior authorization. They also include requirements for certain payers to include a specific reason…
Last month, ICER released their 2023 “Assessment of Barriers to Fair Access” . The report concludes the following regarding 18 drugs evaluated. ICER defines “fair access” based on the following criteria: Cost sharing Cost sharing based on net price. Patient cost sharing should be based on the net price to the plan sponsor, not the…
Form Kaiser Health News: That’s why desperate patients like Nix — and even some physicians — say they have turned to publicly shaming insurance companies on social media to get tests, drugs, and treatments approved.“Unfortunately, this has become a routine practice for us to resort to if we don’t get any headway,” said Shehzad Saeed,…
That is the title from a recent N.Y. Times article. Here is an excerpt: There’s a general sense that all that unpaid labor required to get medical care is increasing. This is in part because as health costs spiral upward, health plans have tried to find incentives to steer treatment to reduce costs. These incentives…
Specialty drugs have delivered significant improvements to patient health, but oftentimes they pay be expensive. To try to insure that these treatments are used appropriately, some health plans impose a utilization management tool known as “prescriber requirements” where only certain types of physicians may prescribe a drug. While this may be useful for some complex…