[Pubmed] Factors that increase utilization management risk: a proof of concept

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Am J Manag Care. 2025 Jun;31(6):288-294. doi: 10.37765/ajmc.2025.89748.

ABSTRACT

OBJECTIVES: To (1) develop a metric that quantitatively measures the risk that utilization management (UM) policies pose to patients and (2) measure the relationship between this metric and payers' real-world UM use.

STUDY DESIGN: We conducted a targeted literature review and an expert elicitation exercise to create the Data-Based Utilization Management Risk Designation (BURDEN) score. Real-world data analysis measured the relationship between BURDEN and actual payer policies.

METHODS: The BURDEN score was based on 9 UM factors impacting patient outcomes. Factors were weighted based on an expert elicitation procedure with 6 stakeholders. UM policy restrictions were drawn from Tufts Medical Center's Specialty Drug Evidence and Coverage database, and net price data came from SSR Health. Ordinary least square regressions were performed to examine the relationship between the BURDEN score and coverage policies.

RESULTS: Among 98 treatments identified across 30 unique diseases, UM policies on treatments for myasthenia gravis, multiple myeloma, and lupus nephritis posed the highest risk to patients, according to the BURDEN score. When treatments had a high BURDEN score, payers were 22.0% less likely to impose any UM restriction (P = .041) and 36.2% less likely to impose step edits (P = .039).

CONCLUSIONS: This study developed a quantitative measure (BURDEN) to estimate the relative risk to patients of payer UM policies. Payers appeared modestly sensitive to treatments that posed a high risk to patients should UM be implemented. However, coverage decisions did not appear to be fully patient-centered, as some higher BURDEN products experienced increased UM usage.

PMID:40549349 | DOI:10.37765/ajmc.2025.89748


Source: https://pubmed.ncbi.nlm.nih.gov/4054934 ... t9+e462414