Managed Care Pharmacy Issues

Population health management (PHM) is a key concept in managed care. Improving population health, enhancing the patient experience, and reducing per capita cost are the primary goals of a philosophy called the Triple Aim. PHM extends beyond healthcare organizations, requiring the cooperation of other types of institutions, such as public health departments and social service entities.

The purpose of outcomes research per the Patient Centered Outcomes Research Institute (PCORI) is to assist patients, clinicians, purchasers and policy makers in making informed health decisions by advancing quality and relevance of evidence. The Agency for Healthcare Research and Quality (AHRQ) defines the purpose of outcomes research as a tool to provide evidence about benefits, risks, and results of treatments so clinicians and patients can make more informed decisions.

Health plans, employers and government-sponsored health care programs are focusing their attention on optimizing patient outcomes through the use of medications that have established evidence of efficacy and safety, while providing the highest value.

Disease management is the concept of reducing health care costs and improving quality of life for individuals with chronic conditions by preventing or minimizing the effects of the disease through integrated care. Disease management programs are designed to improve the health of persons with chronic conditions and reduce associated costs from avoidable complications by identifying and treating chronic conditions more quickly and more effectively, thus slowing the progression of those diseases.

Congress passed the Health Insurance Portability and Accountability Act (HIPAA) in 1996. Within that Act are privacy provisions with which covered entities (including all health plans, health care providers and health care clearinghouses [e.g. PBMs] that transmit any health information in electronic form must comply. HIPAA rules provide guidance to covered entities about how to comply with the Act.

The purpose of this paper is to explain how managed care organizations (MCOs) are able to secure lower drug prices from pharmaceutical manufacturers as part of an effort to control drug expenditures.

Over the past several years, the introduction, utilization and cost share of specialty pharmacy products has been increasing at a rate substantially greater than that of other pharmaceuticals. This paper examines the characteristics of specialty pharmaceuticals; the growth of new expertise to handle and manage these pharmaceuticals; and the needs these products create for patients, health plans and practitioners.

Drug utilization review (DUR) is defined as an authorized, structured, ongoing review of prescribing, dispensing and use of medication. DUR encompasses a drug review against predetermined criteria that results in changes to drug therapy when these criteria are not met.

E-prescribing is the use of health care technology to improve prescription accuracy, increase patient safety, and reduce costs as well as enable secure, real-time, bi-directional, electronic connectivity between clinicians and pharmacies. This is achieved by providing prescribers with a secure means of electronically accessing health plan formulary, patient eligibility, and medication history at the point of care and securely transmitting the prescription electronically into the pharmacy’s computer system.

Formulary management is an integrated patient care process which enables physicians, pharmacists and other health care professionals to work together to promote clinically sound, cost-effective medication therapy and positive therapeutic outcomes. Effective use of health care resources can minimize overall medical costs, improve patient access to more affordable care and provide an improved quality of life.

Press Release: Focusing on what’s best for the patient, leveraging technology to perform real-time benefit checks, and developing trust and transparency among stakeholders are some of the suggestions to emerge from AMCP’s recent Partnership Forum on “Optimizing Prior Authorization for Appropriate Medication Selection.”