New Survey: Utilization Management Delays Cancer Care; Leads to More Stress and Contributes to Worse Outcomes

Patient Advocates on Capitol Hill Echo Survey Findings Showing Strong Patient and Provider Opposition to Proposed Changes to Medicare “Six Protected Classes” Drug Coverage

March 28, 2019

Washington, D.C.—March 28, 2019—A new nationwide survey of cancer patients, caregivers and doctors details the negative effects insurance utilization management policies in private insurance have had on patient care and what those policies could mean should proposed changes to Medicare’s Part D’s “six protected classes” prescription drug coverage policy go into effect.

The American Cancer Society Cancer Action Network (ACS CAN) released the survey Thursday, which showed 1 in 3 (34%) cancer patients and more than half (56%) of doctors reported having to wait for an insurance plan to approve a cancer treatment, test or prescription drug because of utilization management policies resulting in delayed patient care. The most common policies doctors encountered were prior authorization (96%), mandatory generic substitution (90%), quantity limits on prescription drugs dispensed (89%) and having to use a lower-cost drug first in what’s often known as “fail first” or “step therapy” (88%).

Patients and caregivers reported that utilization management requirements like step therapy and prior authorization delayed their care, increased their stress and frustration, contributed to worse outcomes and cost them more out of pocket. Doctors reported that these requirements made it harder for them to treat patients, delayed treatment and were time consuming.

Currently, Medicare Part D plan sponsors are required to cover all or substantially all drug therapies in the designated six protected classes, which cover drugs for cancer, epilepsy, HIV/AIDS, mental illness and organ transplants. However, last November the Department of Health and Human Services (HHS) announced a proposal to allow health plan administrators to extend the use of utilization management tools, like pre-authorization and step therapy, to protected class drug therapies.

“These findings clearly show utilization management is negatively impacting cancer care. Delayed treatment can have life-threatening consequences, especially for cancer patients, and is exactly why Medicare’s six protected classes were created in the first place,” said Lisa Lacasse, president of ACS CAN. “Patients need to have timely access to the best and most appropriate drugs to treat their disease.”

More than 50 patients, providers and caregivers representing 23 different organizations will echo these concerns on Capitol Hill today meeting with Members of Congress to ask them to oppose the administration’s proposal.

According to the survey, most cancer patients, caregivers and physicians oppose all the most common utilization management techniques, especially prior authorization (60% patients, 84% doctors) and having to take a lower cost drug (step therapy) first (68% patients, 78% doctors).

“Targeted cancer therapies with no clinical equivalent are coming onto the market with increasing frequency, but they won’t do any good if patient access is delayed, which could threaten the effectiveness of the therapy itself,” said Lacasse. “Patients need to be heard on this critical issue. We call on Congress to deliver a strong message to the administration to withdraw these proposed changes.”

The survey of more than 400 patients, caregivers and providers was conducted by Public Opinion Strategies and Hart Research Associates in January 2019.

Read the full survey memo:

The patient and provider groups engaging lawmakers include: AIDS United, American Cancer Society Cancer Action Network (ACS CAN), American Society of Clinical Oncology (ASCO), American Society of Consultant Pharmacists (ASCP), American Society for Radiation Oncology (ASTRO), Alliance for Patient Access, Cancer Support Community, Colorectal Cancer Alliance, Epilepsy Foundation, Hepatitis B Foundation, International Myeloma Foundation, Lung Cancer Alliance, LUNGevity, Lupus Foundation of America, MAPRx Coalition, Melanoma Research Foundation, Mens Health Network, Mental Health America, Movement Disorders Policy Coalition, National Alliance on Mental Illness, National Ovarian Cancer Coalition, National Patient Advocate Foundation and the Oncology Nursing Society.

Media Contacts

Allison Miller
Director, Media Advocacy
Washington, DC
Alissa Crispino
Vice President, Media Advocacy
Washington, DC