How often do health plans use “provider requirements”? – Healthcare Economist

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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 therapies, it may also limit access and increase provider administrative burden.

A study be Lenahan et al. (2021) uses data from data from the Tufts Medical Center Specialty Drug Evidence and Coverage (SPEC) database to determine the frequency with which these provider requirements are occurring among commercially insured individuals.  The SPEC database includes publicly available coverage information issued by 17 large US health plans (11 regional and 6 commercial health plans) for their commercial lines of business and includes 311 specialty unique drugs or 647 drug-indication pairs.  The authors examine the share of specialty drugs where plans required: (1) consultation, supervision, or coordination with a specialist; (2) prescription by a specialist (eg, a neurologist); or (3) prescription by a specialist with particular expertise (eg, a neurologist with an expertise in Duchenne muscular dystrophy).

Using this approach, the authors find that:

…health plans imposed prescriber requirements in 22.0% (1,844/8,383) of coverage decisions, which was less often than plans imposed step therapy protocols (29.3%; 2,453/8,383), but more often than plans imposed patient subgroup restrictions (15.8%; 1,327/8,383). In 12.8% (1,073/8,383) of decisions, plans imposed patient subgroup restrictions and/or step therapy protocols in the same decisions as they imposed prescriber requirements; in 9.2% (771/8,383) of decisions, plans did not impose patient subgroup restrictions or step therapy protocols in the same decisions as they imposed prescriber requirements…

Of prescriber requirements, 79.1% (1,459/1,844) required that the drug be prescribed in consultation, supervision, or coordination with a specialist; 18.3% (338/1,844) required that the drug be prescribed by a specialist; and 2.6% (47/1,844) required that the drug be prescribed by a specialist with particular expertise.

Out of the 17 plans in the data, 15 used some sort of provider requirements, but the share of drug-indication pairs in each plan with provider requirements varied from 0.8% to 86.0%). The most common indications where provider requirements were used were: postpartum depression, spinal muscular atrophy, thyroid eye disease, treatment-resistant depression, and hereditary transthyretin-mediated amyloidosis, all with provider requirements in more than 65% of coverage decisions. Provider requirements were less common for oncology than non-oncology products.

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