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Drug utilization management drains $93 billion a year, study shows


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Insurance companies often restrict University of Utah Health physicians from prescribing the optimal drug for a patient s illness.
Providers are left to choose between the second or third choice after insurers initially deny coverage, in part, to steer doctors and patients toward lower-cost options. In some cases, patients have to go through months of ineffective treatment to merit a more expensive drug, said Erin Fox, senior pharmacy director at University of Utah Health, which has an entire pharmacy technician team devoted to prior authorizations.
Our providers are overall especially frustrated with prior authorizations because they often aren t allowed to prescribe what would be the best treatment for an individual patient, she said, noting the step therapy or fail first requirement. The patient has to pay copayments for these visits and may suffer overall worsening of disease state while they make the case to the payer. ....

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COVID-19 raises questions on Medicare pay restructuring in SNFs


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Only a few months after CMS massively changed how skilled nursing facilities are reimbursed for therapy services, the pandemic hit and threw long-term care operations into a tailspin.
That makes it difficult to determine exactly how the change affected therapy services and therapists in nursing homes, researchers say.
A report published in Health Affairs on Monday shows that therapist staffing levels were cut in anticipation of and after the change to the patient-driven payment model in October 2019. The new model replaced the long-standing Resource Utilization Group payment system, known as RUG, with general support from the post-acute care industry. But, after the fourth quarter of 2019, there isn t reliable data to further track the changes, the authors said. ....

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