Key Takeaway
- Health plans adopted medical management tools, including medical necessity reviews, formulary and provider tiered network designs, prior and concurrent authorization, and step therapy approaches, to improve care and reduce costs.
- Medical management tools help ensure care is consistent with evidence-based practices.
- The value of medical management has been recognized in numerous federal and state government-sponsored programs like Medicare.
- It is critical that policy makers recognize the value of these tools and activities and their effectiveness in addressing long-standing challenges to safe and affordable evidence-based health care.
Background
Over the last decade, various landmark reports from the Institute of Medicine (IOM) and the Agency for Healthcare Research and Quality (AHRQ) have brought attention to the significant gaps that exist between evidence-based best practices and the care actually being delivered to patients. Wide variation in provider performance and the little to no correlation between spending and health care quality have been well-documented by researchers and policy experts at Dartmouth, RAND, and the IOM, among others. Safety concerns also persist, particularly regarding new therapies without a proven track record, therapies prone to overuse, and treatments that may only be effective for specific conditions or populations. Underscoring the need for tools to support clinical decision-making and strategies to address these challenges, recent findings show beneficiaries in the traditional Medicare program receive a significant amount of “low-value” care – services that have little or no clinical benefit or where the risk of harm from the service outweighs the potential benefit.