Utilization Management Trends in Medicare Part D Oncology Drugs, 2010-2020

Kyle, Michael Anne; Dusetzina, Stacie B.; Keating, Nancy L.

doi:10.1001/jama.2023.10753

Cited by 5 publications

(4 citation statements)

References 5 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Event study plots showed a decrease in time to treatment initiation in each successive year after an oncologist practice opened an on-site pharmacy, but the overall decrease of 6 days was not statistically significant and likely not clinically significant. There may well be a limit to how much physician-pharmacy integration can reduce time to treatment initiation since many oral anticancer drugs require prior authorization, which is believed to delay the treatment start date by 2 weeks on average …”

Section: Discussionmentioning

confidence: 99%

Cancer Treatment Before and After Physician-Pharmacy Integration

Kanter,

Ozluk,

Chi

et al. 2024

JAMA Netw Open

View full text Add to dashboard Cite

ImportanceIntegration of pharmacies with physician practices, also known as medically integrated dispensing, is increasing in oncology. However, little is known about how this integration affects drug use, expenditures, medication adherence, or time to treatment initiation.ObjectiveTo examine the association of physician-pharmacy integration with oral oncology drug expenditures, use, and patient-centered measures.Design, Setting, and ParticipantsThis cohort study used claims data from a large commercial insurer in the US to analyze changes in outcome measures among patients treated by pharmacy-integrating vs nonintegrating community oncologists in 14 states between January 1, 2011, and December 31, 2019. Commercially insured patients were aged 18 to 64 years with 1 of the following advanced-stage diagnoses: breast cancer, colorectal cancer, kidney cancer, lung cancer, melanoma, or prostate cancer. Data analysis was conducted from May 2023 to March 2024.ExposureTreatment by a pharmacy-integrating oncologist, ascertained by the presence of an on-site pharmacy or nonpharmacy dispensing site.Main Outcomes and MeasuresOral, intravenous (IV), total, and out-of-pocket drug expenditures for a 6-month episode of care; share of patients prescribed oral drugs; days’ supply of oral drugs; medication adherence measured by proportion of days covered; and time to treatment initiation. The association between an oncologist’s pharmacy integration and each outcome of interest was estimated using the difference-in-differences estimator.ResultsBetween 2012 and 2019, 3159 oncologists (745 females [27.1%], 2002 males [72.9%]) treated 23 968 patients (66.4% female; 53.4% aged 55-64 years). Of the 3159 oncologists, 578 (18.3%) worked in practices that integrated with pharmacies (with a low rate in 2011 of 0% and a high rate in 2019 of 31.5%). In the full sample (including all cancer sites), after physician-pharmacy integration, no significant changes were found in oral drug expenditures, IV drug expenditures, or total drug expenditures. There was, however, an increase in days’ supply of oral drugs (5.96 days; 95% CI, 0.64-11.28 days; P = .001). There were no significant changes in out-of-pocket expenditures, medication adherence, or time to treatment initiation of oral drugs. In the breast cancer sample, there was an increase in oral drug expenditures ($244; 95% CI, $41-$446; P = .02) and a decrease in IV drug expenditures (–$4187; 95% CI, –$8293 to –$80; P = .05).Conclusions and RelevanceResults of this cohort study indicated that the integration of oncology practices with pharmacies was not associated with significant changes in expenditures or clear patient-centered benefits.

show abstract

Section: Discussionmentioning

confidence: 99%

Cancer Treatment Before and After Physician-Pharmacy Integration

Kanter,

Ozluk,

Chi

et al. 2024

JAMA Netw Open

View full text Add to dashboard Cite

show abstract

“…Our research design would not have been feasible for studying inpatient hospital admissions because PA policies typically only apply to elective hospital admissions, which are difficult to identify in administrative claims. Similarly, it was not feasible to examine PA for prescription drugs in Part D because PA is widespread in Part D 53 and our research design relied on healthcare utilization data in a setting that lacked PA. 54 Second, our estimates were based on utilization patterns of traditional Medicare beneficiaries, which may differ from those of Medicare Advantage beneficiaries; again, this limitation resulted from our need to employ utilization data from a setting lacking PA. Third, our analysis uses traditional Medicare prices, which can differ slightly from Medicare Advantage. Fourth, we compared the PA policies of five Medicare Advantage insurers, which may differ from those of other insurers.…”

Section: Discussionmentioning

confidence: 99%

Comparison of prior authorization across insurers: cross sectional evidence from Medicare Advantage

Gupta,

Fein,

Newhouse

et al. 2024

BMJ

View full text Add to dashboard Cite

Objective To measure and compare the scope of US insurers’ policies for prior authorization (PA), a process by which insurers assess the necessity of planned medical care, and to quantify differences in PA across insurers, physician specialties, and clinical service categories. Design Cross sectional analysis. Setting PA policies for five insurers serving most of the beneficiaries covered by privately administered Medicare Advantage in the US, 2021, as applied to utilization patterns observed in Medicare Part B. Participants 30 540 086 beneficiaries in traditional Medicare Part B. Main outcome measures Proportions of government administered traditional Medicare Part B spending and utilization that would have required PA according to Medicare Advantage insurer rules. Results The insurers required PA for 944 to 2971 of the 14 130 clinical services (median 1899; weighted mean 1429) constituting 17% to 33% of Part B spending (median 28%; weighted mean 23%) and 9% to 41% of Part B utilization (median 22%; weighted mean 18%). 40% of spending ($57bn; £45bn; €53bn) and 48% of service utilization would have required PA by at least one insurer; 12% of spending and 6% of utilization would have required PA by all insurers. 93% of Part B medication spending, or 74% of medication use, would have required PA by at least one Medicare Advantage insurer. For all Medicare Advantage insurers, hematology and oncology drugs represented the largest proportion of PA spending (range 27-34%; median 33%; weighted mean 30%). PA rates varied widely across specialties. Conclusion PA policies varied substantially across private insurers in the US. Despite limited consensus, all insurers required PA extensively, particularly for physician administered medications. These findings indicate substantial differences in coverage policies between government administered and privately administered Medicare. The results may inform ongoing efforts to focus PA more effectively on low value services and reduce administrative burdens for clinicians and patients.

show abstract

Section: Introductionmentioning

confidence: 99%

“…However, PA processes may require clinicians and patients to navigate a complex approval pathway and can lead to delays in receipt of care or denials of recommended treatment. [1][2][3] Utilization management through PA has been increasing over time, 4 and resultant delays and denials can be particularly problematic for patients with cancer, who often need urgent treatment or symptom management. 5 Oncologists have reported suboptimal care and delays in cancer treatment owing to PA's bureaucratic interference in clinician-patient decision-making; an oncology survey found that payer pressures, including handling PA, ranked as the most pressing practice concern.…”

Section: Introductionmentioning

confidence: 99%

The Patient Experience of Prior Authorization for Cancer Care

Chino,

Baez,

Elkins

et al. 2023

JAMA Netw Open

View full text Add to dashboard Cite

ImportancePrior authorization (PA) requires clinicians and patients to navigate a complex approval pathway. Resultant delays and denials can be particularly problematic for patients with cancer, who often need urgent treatment or symptom management.ObjectiveTo investigate the patient perspective of PA for cancer-related care, including perceptions about the process, outcomes (including delays and denials), and patient administrative burden.Design, Setting, and ParticipantsThis cross-sectional, anonymous survey used a convenience sample of patients with PA experience. Participants were recruited using social media and email lists of US-based cancer advocacy organizations from July 1 to October 6, 2022.ExposurePrior authorization for any cancer-related service.Main Outcomes and MeasuresDelays to care, outcome of PA, communication, and changes in anxiety (measured on a scale of 0-100, with 0 indicating no anxiety and higher scores indicating higher levels of anxiety) and trust.ResultsOf 178 respondents (158 women [88%], 151 non-Hispanic White respondents [84%], 164 respondents [92%] &lt;65 years), 112 (63%) reported that their cancer care was approved and given as recommended, and 39 (22%) did not receive recommended care due to delays or denials. Most respondents (123 [69%]) reported a PA-related delay in care; of those with delayed care, 90 (73%) reported a delay of 2 or more weeks. Most respondents (119 [67%]) had to personally become involved in the PA process; 35 (20%) spent 11 or more hours dealing with PA issues. Overall, the PA experience was rated as bad (70 [40%]) or horrible (55 of 174 [32%]); ratings were associated with the length of delay (ρ = 0.36; P &lt; .001) and the time spent on PA (ρ = 0.42; P &lt; .001). Self-reported PA-related anxiety was higher than usual anxiety (mean [SD] score, 74.7 [20.2] vs 37.5 [22.6]; P &lt; .001) and was correlated with delay length (ρ = 0.16; P = .04), time spent on PA (ρ = 0.27; P &lt; .001), and overall PA experience (ρ = 0.34; P &lt; .001). After PA, 159 respondents (89%) trusted their insurance company less, and 148 respondents (83%) trusted the health care system less. Patient involvement in the PA process was associated with increased odds of distrusting their insurance company (β = 6.0; 95% CI, 1.9-19.2) and the health care system (β = 3.3; 95% CI, 1.4-8.1) and of having a negative experience (β = 6.6; 95% CI, 3.1-14.3).Conclusions and RelevanceThis survey-based cross-sectional study of the patient experience with PA highlights an adverse outcome of PA: 22% of patients did not receive the care recommended by their treatment team because of PA. Most respondents experienced a delay in recommended oncology care, and delays were associated with increased anxiety, a negative perception of the PA process, and patient administrative burden.

show abstract

Utilization Management Trends in Medicare Part D Oncology Drugs, 2010-2020

Abstract: This study examines the exposure of Medicare Part D beneficiaries to utilization management, such as prior authorization, for oral oncology drugs.

Cited by 5 publications

References 5 publications

Cancer Treatment Before and After Physician-Pharmacy Integration

Cancer Treatment Before and After Physician-Pharmacy Integration

Comparison of prior authorization across insurers: cross sectional evidence from Medicare Advantage

The Patient Experience of Prior Authorization for Cancer Care

Contact Info

Product

Resources

About