Prescription Drugs: Finding the Balance between Quality, Effectiveness,

1
Prescription Drugs Finding the Balance between
Quality, Effectiveness, Cost
Judith A. Cahill, CEBS Executive
Director Academy of Managed Care
Pharmacy October 20, 2009
2
Pharmacy Tools to Achieve Cost Effectiveness and
Quality

• Formulary Management
• Drug Utilization Review
• Patient Education
• Quality Measures

3
Formulary Management

• A Formulary is evaluated at a therapy class level
  and must be clinically complete and up-to-date
• Decisions are made by PT committees
• Membership is primarily physicians and
  pharmacists
• Includes practitioners from a variety of
  specialties
• May also include members from other divisions of
  healthcare
• Nursing, Nutritional Services, Administration,
  Law, Quality Assurance

4
Factors Considered by PT Committee

• Founded in Evidence-Based Medicine
• Clinical efficacy
• Safety
• Therapeutic need
• Clinical guidelines
• Standards of medical practice
• Pharmacoeconomics
• Cost

5
Innovations for PT Committees

• AMCP Format for Formulary Submissions, Version
  3.0
• AMCP eDossier System powered by Dymaxium

6
Innovations for Formulary Systems

• Comparative Effectiveness Research Applied
• Value Based Insurance Design
• Higher Tiers/Multiple Tiers
• Health Savings Account

7
Formulary Management System Tools

• Prior Authorization
• Step Therapy
• Tiering
• Physician Compliance
• Therapeutic Interchange
• Generic Substitution

8
Goals of Drug Utilization Review

• Monitor quality of care
• Minimize drug misuse and abuse
• Encourage the practice of evidence-based,
  clinically appropriate, cost-effective drug use
• Reduce costs related to inappropriate drug use
• Confounded by 4 copay programs

9
The DUR Process Prospective, Concurrent, and
Retrospective

• Determine criteria
• Collect data
• Compare the data to established criteria
• Perform intervention
• Analyze results
• Document DUR
• Re-evaluate the program (on-going)

10
The Role for Effective MIS

• MIS provides data management and clinical data
• MIS merges multiple data sources such as
  eligibility, drug utilization review, and
  copayment information
• MIS facilitates the process of interventions and
  reporting of pharmacy data

11
Reporting

• Benefits of reporting
• Trend analysis
• Assessment of drug utilization and associated
  costs
• Evaluation of prescribing/use patterns
• Evaluation of intervention programs
• Assessment of patient compliance
• Evaluation of MTM programs

12
Patient Education

• Program goals
• Increase awareness of preventive care
• Improve health behaviors
• Improve member satisfaction with health care
  services
• Potentially reduce overall medical costs
• Encourage appropriate use of generics

13
Motivating Factors for Patients

• Decreased out of pocket costs
• Self care education
• Empowerment in maintenance of personal health
• Support systems
• Incentives for self care

14
Typical Programs

• Letters
• Phone calls
• Pharmacist run services
• Program examples
• Disease state management programs
• Medication therapy management (MTM)
• Compliance programs
• Formulary (brand versus generic) and copayment
  education
• Pay-for-performance incentives

15
Quality Measures in Ambulatory Pharmacy

• Introduced with Medicare Part D
• Draws on managed care pharmacys experience
• Emphasis Pay for Value not Volume
• Many entrants PQA, NQF, URAC, NCQA, QIOs

16
Contact Information

• Judith A. Cahill, CEBS
• Executive Director
• Academy of Managed Care Pharmacy
• 100 North Pitt Street, Suite 400
• Alexandria, VA 22314
• jcahill_at_amcp.org
• www.amcp.org