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Research Paper | Pharmacy | United States of America | Volume 6 Issue 10, October 2017 | Popularity: 4.5 / 10

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Utilization Management Techniques in the United States Managed Care Ecosystem

Dinesh Kabaleeswaran

Abstract: The United States healthcare system tends to be complex often dominated by multiple stakeholders including payers, providers, specialty pharmacies, pharmacy benefit managers, integrated delivery providers, group purchasing organizations, apart from just the patient and the pharma manufacturers. Millions of dollars are pumped into the healthcare system to develop new therapies that treat patients with life threatening conditions such as oncology and specific rare diseases. Given the focus on dollars spent, payers and other stakeholders in the healthcare systems are involved in controlling costs for their business and they achieve this through a variety of utilization management techniques which optimize or in some cases limit access to life saving therapies. This study reviews the utilization management techniques developed and imposed the managed care organizations through formulary designs, prior authorization policies, step therapy, and other such limitations. Ultimately, it is important that the patient is the final beneficiary and therefore it is critical that all stakeholders work towards a system that is mechanized to work towards patients being able to access high-cost therapies for oncology and rare diseases.

Keywords: managed care, formulary design, life sciences, tiering structures, prior authorization

Edition: Volume 6 Issue 10, October 2017

Pages: 2177 - 2179

DOI: https://www.doi.org/10.21275/ES24506082057

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