Impact of Patient Cost Sharing on Specialty Drug Utilization, Prior Authorization

Higher levels of patient cost sharing were associated with decreased specialty drug utilization, largely due to medication abandonment and reduced therapy initiation, according to findings published in the Journal of Managed Care & Specialty Pharmacy.

This study aimed to investigate the impact of patient cost sharing on specialty drug utilization and the effects of prior authorization on treatment delay and specialty drug utilization.

Specialty drugs, characterized by high costs and complex administration, are subject to utilization management strategies such as prior authorization and higher cost sharing tiers by payers to control spending. However, these strategies can have negative consequences on patients' health outcomes, including delays in treatment initiation, medication abandonment, and nonadherence, researchers said.

A literature search was conducted from February 2021 to April 2022, utilizing PubMed for English articles without restriction on publication date. After screening and exclusions, a total of 44 studies were included in the review, consisting of 9 on prior authorization and 35 on cost sharing. Review papers, opinion pieces, and projects without data were excluded.

The findings indicate patients who had lower cost sharing through patient support programs demonstrated higher adherence, shorter time to fill prescriptions, and lower rates of medication discontinuation. Similar positive outcomes were observed for patients enrolled in low-income subsidy programs. 

On the other hand, cost sharing above $100 was associated with abandonment rates of up to 75% for specific specialty drugs. Higher cost sharing was also linked to increased discontinuation rates and odds. 

However, the impact of cost sharing on medication possession ratio (MPR) and proportion of days covered (PDC) yielded inconsistent results. While some studies reported a negative association between higher costs and MPR/PDC, MPR and PDC for cancer specialty drugs did not decrease with increased costs. 

Furthermore, significant delays in prescription initiation were reported when prior authorization was required.

In conclusion, higher levels of patient cost sharing were found to reduce specialty drug utilization by increasing medication abandonment while decreasing initiation and persistence overall. Conversely, programs that lowered patient cost sharing demonstrated increased initiation and persistence rates, according to the findings. 

The impact of cost sharing on MPR and PDC was inconsistent and bidirectional, researchers concluded. Prior authorization was associated with treatment delays, although its effects on specialty drug use varied. 

Reference:
Ismail WW, Witry MJ, Urmie JM. The association between cost sharing, prior authorization, and specialty drug utilization: A systematic review. J Manag Care Spec Pharm. 2023;29(5):449-463. doi:10.18553/jmcp.2023.29.5.449