While your pharmacy benefit program has no doubt been managing utilization for years with core strategies, it's important to review effectiveness often. Below are the proven strategies that payers should analyze frequently in the current market of increasing utilization.
Payers and employers can pay up to $350,000 per patient for just one year of treatment for high-cost conditions such as rheumatoid arthritis. Patients, too, share the burden, in some cases shouldering 50% of the bill in deductibles and co-pays.
Antipsychotics are the fourth largest group of medications prescribed in the United States today, with a collective cost of approximately $10 billion. Newer, second-generation medications represent 90% of the current market, and they cost considerably more than older antipsychotics.
Findings of a study released earlier this year suggest that the average cost of dispensing prescriptions may be higher than the average dispensing fees paid to pharmacies.
Employers are putting more financial burden on employees in the form of higher copays and deductibles, however, in the physician's office, patients' cost concerns usually aren't discussed in advance of a particular treatment.
Trumpeting the now-popular battle cry of transparency, many states are attempting to control the contractual arrangements between pharmacy benefit services providers and their clients. Because of the historical issues around hidden revenue streams and misaligned objectives, it is no wonder the public sector is taking note.
State regulation of pharmacy benefit managers (PBMs) would benefit states and consumers by providing a regulatory framework for the only entity involved in delivery of a healthcare benefit to the consumer that is largely unregulated.
If the rate of growth for specialty-drug spending were to continue at 20% a year, it would account for more than 25% of all outpatient pharmacy spending by 2008, as reported in the CuraScript's Specialty Pharmacy Management Guide and Trend Report. The estimated size of the specialty pharmacies market grew to approximately $40 billion in 2005, with projections reaching nearly $75 billion in 2008.
LOW-PREVALENCE rheumatoid arthritis (RA) has not gained attention equal to that of more common chronic diseases, but it has earned a spot on the list of complex diseases ripe for disease management.
LOW-PREVALENCE rheumatoid arthritis (RA) has not gained attention equal to that of more common chronic diseases, but it has earned a spot on the list of complex diseases ripe for disease management.
THE BEST STEP therapy programs first consider medical evidence regarding patient outcomes when identifying drug classes for inclusion, according to industry experts.
IN THE PAST TWO DECADES, the progress of pharmacy benefit management has brought about sophisticated strategies including formularies, utilization management and generic substitution. David B. Snow Jr., CEO of Medco Health Solutions, is bargaining that the next decade of pharmacy benefit management will bring enhanced patient therapy, personalized medicine and dramatic opportunities in the generic market-points all pharmacy benefit teams will have to ponder.
What makes the high cost of a drug worth it? Does the intervention have to save a life? Or prevent the onset of a more expensive condition? Or add six months to patient survival? It's all in the eye of the beholder-whether you are a payer, patient or provider.
Washington, D.C.-Sierra Health Services recently disclosed a $2 million monthly loss from its Medicare full donut-hole-coverage prescription drug plan (PDP), blamed the financial problem on a competitor, and decided to sell out to the leader in the field. Sierra executives say they will drop the Sierra Rx Plus plan, which pays for brand-name drugs through the Medicare coverage gap for its 42,000 members, and the new owner, UnitedHealth Group is unlikely to question that decision.
Washington, D.C.-The need to reauthorize the Prescription Drug User Fee Act (PDUFA) before it expires Sept. 30, 2007, has set the stage for Congressional action on broader legislation to enhance government regulation of drug safety. Bills under consideration aim to expand Food and Drug Administration (FDA) oversight by establishing new requirements for postmarket risk assessment, for posting information on active clinical trials and the resulting study data, and for completing agreed-upon postmarketing studies.
Surgical site infections are a significant problem in hospitals today. They occur in 2% to 5% of patients who have clean operations outside the abdomen, and in up to 20% of patients with intra-abdominal procedures. They account for about 15% of hospital-acquired infections.
Over the next few years, more health plans and employers will investigate covering the physician-administered injectable drugs under the pharmacy benefit as a way to control the costs and manage appropriate utilization, says Kathryn Lindhorst Canaday, PharmD, director of pharmacy analysis, Pharmaceutical Strategies Group (PSG), based in Dallas.
As health plans elect to cover a new FDA-approved vaccine that protects girls and women against strains of the human papillomavirus (HPV), parents might wonder if it will be mandated by states as a routine immunization for girls at a certain age.
New drug delivery methods have potential to improve compliance through ease of use, but have brought up some new questions. Is reconfiguring an injected insulin into an inhaled version, for example, just a way to relaunch a product, or does the invention provide more than a "me-too" product?
It would seem that any healthcare entity able to introduce lower costs and greater convenience would be welcomed with open arms, if not a genuine ticker-tape parade. Yet, walk-in retail clinics, new players built on low cost and convenience, are struggling to gain a national foothold, and experts aren't sure the new guy will even make it in the end.
Besides an ongoing trend of mergers and acquisitions, other issues are shaping the PBM market, say experts.
Attention-deficit/hyperactivity disorder (ADHD) is marked by patterns of inattention, careless mistakes, difficulty waiting, forgetfulness and restlessness. People who have ADHD are distracted most of the time. Even when they try to concentrate, they find that it's hard to pay attention. They have trouble organizing things, listening to instructions or remembering details. Someone with this condition is impulsive. They often fidget, don't wait for their turn and interrupt others. In school, children with ADHD may blurt out answers and move around a lot; they seem to be "always on the go."
Although as many as 48% of seniors were subject to some type of drug-coverage deficiency in 2006, only an estimated 4 million of the 22.5 million enrolled in Medicare drug plans were actually expected to hit the infamous donut hole. There could still be financial woes, however, for the 10.8 million Medicare beneficiaries who at least have the potential for out-of-pocket costs in the donut hole gap because they do not qualify for a subsidy, are not covered outside Part D, or did not pay for enhanced gap coverage.
National Reports-The recent merger move by retail pharmacy chain CVS and pharmaceutical service company Caremark Rx is not likely to have much near-term significance to the managed care industry, say experts, but over time, MCO customers are likely to experience some change as a result of the two entities' combining their PBM operations.
There is a trend in the medical community where third-year residents are turning away from primary care medicine in favor of more lucrative specialties.
