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Health care practitioners (HCPs), and patients too, are sounding the alarm on unnecessary barriers in the system that can negatively impact patients’ access to quality care according to a new survey of HCPs and patients. Specifically, HCPs raised concerns over how pharmacy benefit managers (PBMs) and insurers inappropriately use utilization management tools, like prior authorization, to deny or delay care, ultimately harming the patient and impacting patient access to care.
These findings build on another recent poll of Americans’ experience with the health care system, which showed Americans face insurer and PBM-imposed barriers to care and demand greater urgency to related policy reforms.
Here are three key insights from the survey:
- Both HCPs and patients say the insurance system is purposely complex, driving unnecessary costs for patients and the system.
- Large majorities of both HCPs (91%) and insured Americans (77%) agree health insurers intentionally make coverage benefits complicated so they can increase their bottom line.
- An overwhelming majority of HCPs (93%) believe health care costs for patients would be lower if insurance companies and PBMs spent less time managing how medicines should be prescribed.
- Both HCPs and patients face challenges and barriers to care due to middlemen's abuse of utilization management tactics and other restrictions.
- 90% of HCPs have had to adjust their care plans because of restrictions (e.g., utilization management) from insurance companies and/or PBMs.
- Three-in-10 (30%) patients report skipping or avoiding needed care because they fear it won’t be covered insurance, or they will face difficulty paying out-of-pocket.
- Half of Americans with insurance (49%) have experienced a prior authorization process, an insurer tactic most HCPs (91%) say has caused delays to care that made them worry for their patients’ health.
- Both HCPs and patients overwhelmingly support policy solutions to rein in middlemen.
- Nearly all (96%) of HCPs and 89% of patients agree doctors, not insurers and PBMs, should determine whether a prescription drug is clinically appropriate.
- And 96% of HCPs support checks on insurance companies and PBMs – including passing on rebates so patients pay less out of pocket.
The message is clear – health care practitioners and patients demand policy reforms to ensure middlemen will not get in the way of their patients’ access to care.
For more on the latest opinion polling and research, visit phrma.org/polling.
Mike Ybarra
Michael Ybarra, M.D., is an emergency physician and Chief Medical Officer at PhRMA. He also serves as Senior Vice President in Advocacy and Strategic Alliances. In these roles, he leads PhRMA’s stakeholder engagement and strategic partnerships on federal and international health policy issues. He is PhRMA’s liaison representative to the Advisory Committee on Immunization Practices and is the co-convener of PhRMA’s R&D Leadership Forum. Dr. Ybarra continues to see patients clinically in the emergency department at MedStar Georgetown University Hospital.
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