hen the design of employers' health benefit plans is chiefly driven by efforts to lower their costs, employees may suffer the consequences, according to opponents of stringent health care cost-containing measures.

Health care utilization management (UM) tactics may be effective in controlling employers' spending, the critics say, but they are not as effective in controlling health care costs for employees and can create unintended barriers to treatment.

That's the position advocated by CancerCare, a nonprofit that provides cancer patients with support services and information. The organization recently published a toolkit of best practices for prescription drug benefits to help benefits managers, HR professionals and executives navigate and understand the consequences of health care use-management strategies, specifically around prescription drugs. The price-controlling features that CancerCare is most critical of include:

• Formulary design—the list of drugs approved by a health plan's pharmacy benefits manager (PBM), CancerCare said, is often influenced more by PBM profit than efficacy or list price, leading to restrictive formularies that can put needed drugs out of patients' reach.
  Advocates of formulary management have said this tactic promotes "clinically sound, cost-effective medication therapy and positive therapeutic outcomes."

• Step therapy—a protocol that requires patients to first try one or a series of PBM-preferred drugs before being allowed the drug prescribed by their clinician. "Step therapy can cause delays in effective treatment, increased costs to patients and adverse side effects or medical setbacks," CancerCare said.
  Health insurers have said that "prior authorization and step therapy ensure that medically sound and cost-effective medications are prescribed appropriately."

• Specialty pharmacies—when patients are required to use specific, often PBM-owned, specialty pharmacies, "it limits their choice as consumers and may result in difficulties receiving and refilling prescriptions," CancerCare said.
  Advocates of specialty pharmacies have said they "are better suited than traditional pharmacies to monitor and track the use of specialty drugs and have the necessary training and expertise to handle their distribution."

• Co-pay accumulator programs—these exclude the dollar amount of financial co-pay assistance, such as discount coupons from drug companies, from deductibles and out-of-pocket totals, "making it more difficult for patients to afford their medication while allowing health plans and pharmacy benefit managers to get paid twice," CancerCare said.
  Defenders of these programs have said they discourage employees from buying overly expensive prescription drugs.

"When cost is the dominant factor in guiding employers' benefits decision-making, employee health can pay the price," said Patricia J. Goldsmith, CancerCare's chief executive officer. "Employers must take care to balance cost savings with the real needs of their employees, especially those with serious or chronic illnesses."

In January, CancerCare collected responses from 50 executives responsible for employee benefits at large U.S. employers. Almost all respondents (94 percent) said employer health care costs were more influential than any other factor, including employee costs and care access, when they made health benefits decisions.

Employers, for their part, are struggling with escalating costs fueled by higher insurance premiums—up 47 percent between 2011 and 2021, according to a Commonwealth Fund study—and often use UM features to keep health care spending from spiraling out of control.

However, among the unintended consequences of doing so, CancerCare said, is delaying or denying necessary and time-sensitive care, as when patients can't afford to buy prescribed medications.

The position is supported by researchers at the nonprofit Kaiser Family Foundation, which surveyed 1,146 U.S. adults last fall and reported that because of the high cost:

• 29 percent of adults were not taking medicines as prescribed.
• 19 percent didn't fill a prescription.
• 12 percent cut pills in half or skipped a dose.

Thirty percent of those who report not taking their medicines say their condition got worse as a result.