What the Growth of Utilization Management Says About the Future of Policy and Patient Access

A new Health Affairs Forefront primer examines the evolution of utilization management and its impact on patient access and policymaking for prescription drugs.

WASHINGTON, DC, UNITED STATES, June 3, 2025 /EINPresswire.com/ -- More than 35 years ago, a prescient committee of health experts flagged concerns about the early practice of utilization management (UM) and its impact on patient access to essential care. Since then, UM has evolved from a novel concept focused on whether proposed surgical or medical services were clinically appropriate into a staple of U.S. health policy and healthcare benefit design aimed at containing costs, particularly for prescription drugs. Over time, numerous studies have demonstrated that UM can harm patients.

A new primer, published in Health Affairs Forefront, recounts the evolution of medication UM strategies over time, how they affect patient care, and the broader implications for future healthcare policy.

The new publication, “Tracing the Arc of Medication Utilization Management Over Time: Implications for Patients and Policy,” was co-authored by Kimberly Westrich, MA; Lisabeth Buelt, MPH; James Motyka, PharmD; and Jon D. Campbell, PhD, of the National Pharmaceutical Council.

Healthcare plans posit that the overarching goal of UM is to promote safer, more appropriate use of medications and avoid unnecessary spending. However, administrative medication UM strategies such as prior authorization requirements, step therapy protocols, quantity limits, formulary/coverage restrictions, and prescriber restrictions are increasingly used as blunt instruments to contain costs and restrict access to many treatments. Moreover, these strategies are often combined with financial UM strategies, including tiered patient cost-sharing and high-deductible health plans, which impose additional barriers to patient access.

"The growth in use of UM strategies for cost-containment coincides with a surge in formulary exclusions by pharmacy benefit managers," said Ms. Westrich, NPC Chief Strategy Officer. "Combined, these tactics are often deployed for nonclinical reasons, limiting patient and provider choice while restricting access to care."

The authors examined the landscape of UM implementation over the past four decades, identifying three key trends that have defined its use and effects on care:

• UM has become commonplace in benefit designs across payer types, affecting many patient populations and treatments. While the strategies chosen by payers may vary, the use of UM continues to increase in both private and Medicare plans.

• UM is increasingly applied to specific therapeutic areas — such as oncology — restricting access for vulnerable patient populations. Since therapeutic substitution may not be appropriate in cancer care, the implementation of UM may result in a critical barrier to access for patients with few existing treatment options.

• Research has shown that UM strategies, such as prior authorizations and step therapy, can have negative effects on patients and the healthcare system, such as disruptions in care, reduced adherence, increased administrative burden, and higher overall expenditures.

Although stakeholders across the healthcare system have raised concerns about the rising use of medication UM, payers continue to expand their use of these strategies. For patients, the resultant implications of this widespread use of UM include the imposition of inappropriate barriers to care and jeopardizing the delivery of clinically appropriate care.

"It’s imperative for policymakers and healthcare decision-makers to critically review the use of UM strategies for prescription drugs and advance more value-based, patient-centered care," said Dr. Campbell, NPC Chief Science Officer.


About the National Pharmaceutical Council
NPC serves patients and society with policy-relevant research on the value of patient access to innovative medicines and the importance of scientific advancement. We envision a world where advances in medicine are accessible to patients, valued by society, and sustainably reimbursed by payers to ensure continued innovation. For more information, visit www.NPCnow.org and follow NPC on LinkedIn.

Michael Pratt
National Pharmaceutical Council (NPC)
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