{"id":6163,"date":"2025-06-04T20:12:18","date_gmt":"2025-06-04T20:12:18","guid":{"rendered":"https:\/\/medical-article.com\/?p=6163"},"modified":"2025-06-04T20:12:18","modified_gmt":"2025-06-04T20:12:18","slug":"factors-that-increase-utilization-management-risk","status":"publish","type":"post","link":"https:\/\/medical-article.com\/?p=6163","title":{"rendered":"Factors That Increase Utilization Management Risk"},"content":{"rendered":"<p>That is the title of a <a href=\"https:\/\/www.ajmc.com\/view\/factors-that-increase-utilization-management-risk-a-proof-of-concept\">new paper published in the <\/a><em><a href=\"https:\/\/www.ajmc.com\/view\/factors-that-increase-utilization-management-risk-a-proof-of-concept\">American Journal of Managed Care (AJMC)<\/a><\/em> with co-authors Jacob Fajnor, Shurui Zhang, and Donald Nichols.  The abstract is below.<\/p>\n<p><strong>Objectives:<\/strong> To (1) develop a metric that quantitatively measures the risk that utilization management (UM) policies pose to patients and (2) measure the relationship between this metric and payers\u2019 real-world UM use.<\/p>\n<p><strong>Study Design:<\/strong>\u00a0We conducted a targeted literature review and an expert elicitation exercise to create the Data-Based Utilization Management Risk Designation (BURDEN) score. Real-world data analysis measured the relationship between BURDEN and actual payer policies.<\/p>\n<p> <strong>Methods:<\/strong>\u00a0The BURDEN score was based on 9 UM factors impacting patient outcomes. Factors were weighted based on an expert elicitation procedure with 6 stakeholders. UM policy restrictions were drawn from Tufts Medical Center\u2019s Specialty Drug Evidence and Coverage database, and net price data came from SSR Health. Ordinary least square regressions were performed to examine the relationship between the BURDEN score and coverage policies.  <\/p>\n<p><strong>Results: <\/strong>Among 98 treatments identified across 30\u00a0unique diseases, UM policies on treatments for myasthenia gravis, multiple myeloma, and lupus nephritis posed the highest risk to patients, according to the BURDEN score. When treatments had a high BURDEN score, payers were 22.0% less likely to impose any UM restriction (<em>P<\/em>\u2009=\u2009.041) and\u00a036.2%\u00a0less likely to impose step edits (<em>P<\/em>\u2009=\u2009.039).<\/p>\n<p><strong>Conclusions: <\/strong>This study developed a quantitative measure (BURDEN) to estimate the relative risk to patients of payer UM policies. Payers appeared modestly sensitive to treatments that posed a high risk to patients should UM be implemented. However, coverage decisions did not appear to be fully patient-centered, as some higher BURDEN products experienced increased UM usage. <\/p>\n<p>You can read the full paper <a href=\"https:\/\/www.ajmc.com\/view\/factors-that-increase-utilization-management-risk-a-proof-of-concept\">here<\/a>.<\/p>","protected":false},"excerpt":{"rendered":"<p>That is the title of a new paper published in the American Journal of Managed Care (AJMC) with co-authors Jacob Fajnor, Shurui Zhang, and Donald Nichols. The abstract is below. Objectives: To (1) develop a metric that quantitatively measures the risk that utilization management (UM) policies pose to patients and (2) measure the relationship between&#8230;<\/p>\n","protected":false},"author":0,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2],"tags":[],"class_list":["post-6163","post","type-post","status-publish","format-standard","hentry","category-articles"],"_links":{"self":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/posts\/6163"}],"collection":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"replies":[{"embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=6163"}],"version-history":[{"count":0,"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/posts\/6163\/revisions"}],"wp:attachment":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=6163"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=6163"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=6163"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}