Utilization Management Barriers
When cost controls interfere with patient care.
What’s Happening
Utilization management (UM) policies—such as prior authorization, step therapy, and other insurer-imposed restrictions—are increasingly being applied to Medicare Part B therapies.
These tools, originally intended to manage unnecessary spending, are now delaying access to care and interfering with clinical decision-making.
As more Medicare Advantage plans and commercial payers adopt aggressive UM strategies, patients and physicians are being forced to navigate complex, opaque approval processes that put timely treatment at risk.
Who it affects
The patients impacted most by utilization management policies are those with complex and chronic conditions, including:
These patients often require specialist-prescribed therapies and close clinical oversight. UM barriers undermine that relationship and can delay critical care.
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Cancer
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Rheumatoid arthritis
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Inflammatory Bowel Disease
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Autoimmune diseases
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Mental illness
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Eye diseases
Why it Matters
Utilization management may reduce short-term costs for insurers, but it often comes at the expense of patient outcomes and provider autonomy.
In short, these policies insert bureaucratic red tape between doctors and their patients—eroding trust, limiting choice, and risking lives.
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Delayed Treatment, Worse Outcomes
Delays in treatment caused by prior authorization can lead to disease progression and poorer clinical outcomes.
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Step Therapy Risks
Step therapy (“fail first”) policies force patients to try lower-cost or less effective therapies before gaining access to what their physician originally prescribed.
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Administrative Overload
Increased administrative burden diverts time and resources away from patient care, particularly in small and community-based practices.
The Financial implications
Navigating MA plans’ ST requirements for physician administered drugs adds significant burden on independent and community practices, which could lead doctors to stop stocking certain medicines and further drive health system consolidation.
The data reveals the real-world consequences for providers—and the patients they serve.
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94%
Of providers experience high or extremely high administrative burden when navigating different MA plans' step therapy policies.
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90%
Of physicians report that prior authorization has delayed patient care.
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30%
Of patients forced into step therapy experience delays or denials in accessing the correct treatment.
Legislative Solution
Safe Step Act of 2025
(Pending reintroduction. 118th legislation S. 652/H.R. 2630)
This bipartisan legislation would:
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Create a clear, fair process for step therapy exceptions in employer and commercial plans
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Ensure patients can access the most appropriate therapy based on medical need—not cost algorithms
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Protect continuity of care for patients already stable on their current treatment