Consumers Blame Payers, Utilization Management for Delays in Care

Consumers do not agree that insurers are protecting them from high out-of-pocket costs and find that utilization management practices—such as prior authorization and formulary exclusions—are culpable for delays in access to care and medications, a survey commissioned by Pharmaceutical Research and Manufacturers of America (PhRMA) found.

“As policymakers evaluate possible reforms to the U.S. health care system, leaders should consider the systemic barriers Americans face when navigating their coverage,” the survey explained. “A thorough understanding of the patient experience will help inform solutions that address patients’ real pain points and protect their access to innovative, life-saving medicines.”

PhRMA’s partner in this survey, Ipsos, contacted over 5,000 Americans between April 4 and April 17, 2023 to have them answer an online questionnaire. Of those who were surveyed, more than 3,440 reported taking prescription medications and over 4,820 stated that they were insured.

When it came to protecting them from high out-of-pocket costs, Americans were not convinced that payers were doing their jobs.

Only a little more than a third of the insured respondents agreed that insurance facilitates affordable access to care for all and nearly 20 percent expected that they would not be able to afford their healthcare costs if they developed a chronic disease or experienced an unanticipated medical event (19 percent).

Respondents blamed utilization management practices like prior authorizations and formulary requirements for delaying access to care and increasing costs. One in five participants had experienced a formulary exclusion (20 percent) and slightly more than that had encountered prior authorizations (22 percent).

More than a third of insured respondents with chronic diseases who are taking medications had experienced utilization management practices (36 percent). The share was even higher for respondents with neurological disorders and mental healthcare needs.

Most participants agreed that insurers should not be the entity that assesses whether a medication is clinically appropriate (93 percent). They preferred that providers fill this role. Additionally, participants largely supported hospital transparency and oversight around medication discounts (92 percent) and that Congress should take action to better regulate insurers’ prescription drug coverage (92 percent).

Of the insured respondents, 747 were in medical debt (17 percent). Most respondents said that the bills contributing to their debts were hospital or doctor bills (59 and 57 percent, respectively). Also, 42 percent of respondents indicated said that the cost of diagnostic tests contributed to their debts.

Insured individuals in the LGBTQ+ community, Hispanic Americans, caregivers, and rural Americans had the highest rates of unaffordable out-of-pocket healthcare costs. Among rural Americans, nearly four in ten found their out-of-pocket healthcare spending unaffordable, despite having health insurance coverage (38 percent).

Out-of-pocket healthcare spending was the top concern for respondents. Almost six out of ten survey participants expressed concern about these costs (57 percent). In comparison, less than half of Americans were worried about the costs of healthy food and transportation (45 percent and 40 percent, respectively).

Three healthcare issues were high priority for most respondents. When compared with a list of several healthcare issues including access to mental healthcare and the cost of prescription medicines, nearly a third of respondents stated that out-of-pocket healthcare costs were the highest priority (32 percent), followed by premium costs (26 percent), and inefficiency in the healthcare system (19 percent).

The policies listed in the survey that garnered the most support included policies that made healthcare spending more predictable, required that insurers’ rebates be passed down to patients in the form of prescription medicine discounts, and reduce the negative effects of accumulator adjustment programs.

Other potential solutions to support low-income and uninsured patients that the survey highlighted included requiring that prescription discounts go toward low-income and uninsured patients and connecting them with resources like the 340B program.