Pharmacy

The growth in high-cost injectable and infusion therapies for the treatment of chronic illnesses is a significant management issue for pharmacy benefit managers and payers, experts say.

Clever approaches can help patients adhere to drug regimens, and managed care organizations are increasingly adopting the technologies that enable those approaches.

The Services provided by PPO plans are influenced by a number of factors, say industry watchers.

One in three (33%) U.S. adults who have been prescribed drugs to take regularly report that they are often or very often not compliant with their medications.

National Reports-Some recent media reports have indicated that the Medicare drug benefit has been responsible for increased earnings for pharmaceutical companies and increased membership for health plans. That may or may not be the case, say industry watchers.

National Reports-As major brand drugs such as Zocor (Merck) and Zoloft (Pfizer) lose patent protection and become available as generics, health plans, employers and patients alike can expect to realize significant savings in the long run, experts say.

Washington, D.C.-The battle between pharmaceutical companies and generics makers is heating up, this time over increased moves by brand-name firms to put out their own low-cost "authorized" generic products. While this strategy undercuts the innovator's price, it probably hurts generics firms even more by greatly diminishing the value of the 180-day exclusivity period for the first generic to market.

Heart failure is a serious condition in which the heart doesn't pump enough blood throughout the body. It may be caused by several different diseases that damage or overwork the heart muscle; the leading causes include coronary artery disease, high blood pressure and diabetes.

Medicare part D has put a new face on pharmaceutical benefits for seniors-even with all the glitches and challenges of implementing the largest social welfare program in 40 years. It welcomed 11.5 million Medicare beneficiaries prior to the May 15, 2006, deadline, according to final Medicare prescription drug benefit enrollment data.

Hospitals are ramping up efforts to improve their medication data collection methods in an attempt to reduce the number of preventable adverse drug events that occur annually. They are establishing guidelines for collecting complete drug and allergy histories and comparing those histories with new medications when patients are admitted to a hospital.

NATIONAL REPORTS-The San Francisco health access plan raises challenges for MCOs, say industry experts.

WASHINGTON, D.C.-There's new evidence that ready access to medications can reduce overall healthcare spending. A study of California Medicare beneficiaries who had a $1,000 annual cap on drug coverage finds that they spent less on drugs, but more on emergency care and hospitalizations. And they had a higher death rate compared with seniors with unlimited drug coverage.

Appropriate benefit design-copay structures and tiers-is an important factor in providing members and patients with access to treatment that is affordable. Meanwhile, cost sharing with consumers continues to increase because of pressures on maintaining competitive premium costs and the lack of innovative means to manage utilization, say experts.

The rhetoric is heating up as health insurers and pharmacy benefit managers (PBMs) try to fend off an escalating attack from retail pharmacists about late or lost payments. Delayed payments are "simply profits these giant corporations will pocket," says National Community Pharmacists Assn. CEO Bruce Roberts. "The PBM industry adds no value to the healthcare delivery system."

BLOOMINGTON, MINN.-Some preventive services contribute more to improving health compared with other preventive services, while others offer more value for the dollar, according to a recent study.

Dose consolidation is getting mixed reviews as a cost-cutting strategy according to pharmacy benefits managers (PBMs). While a study by St. Louis-based Express Scripts indicates that savings opportunities are limited, other PBMs have realized more value. With prescription drugs accounting for 10% of total healthcare expenditures, according to the California Healthcare Foundation's third "Health Care Costs 101" report, a variety of strategies are worth exploring.

The blockbuster drugs of the 1990s came off patent, became generic,and now several of them have become available over-the-counter(OTC). Others are expected to join the ranks in the next few years.This shift, combined with the increasing focus on electronicmedical records (EMRs) for longitudinal patient medication profilesand continuing pressure on the healthcare industry to take costsout of the system, drives the following questions for health plans,employer groups and pharmacy benefit managers (PBMs): Should OTCdrugs be covered by a pharmacy plan? Is benefit design sufficientfor covering OTCs and monitoring therapeutic compliance? Shouldpharmacy and therapeutic (P&T) committees modify theirformularies to be OTC-aware, or should they actually include OTCson the formulary? If a plan does incorporate OTCs into theformulary, what are the criteria for inclusion or exclusion?

There is no question in anyone's mind that the increased use of high-tech diagnostic imaging has significantly improved the diagnosis and treatment of patients during the past decade.

With its first phase of certification rolling, the CertificationCommission for Healthcare Information Technology (CCHIT) willconcentrate on maintaining its momentum while moving to the realmof inpatient electronic health records (EHRs) in its secondcertification phase, followed by the evolving EHR networkinfrastructure in phase three.

Insurance companies are constantly on the lookout for innovativeways to reduce risk and reduce costs. From underwriting continuingeducation for insured physicians to providing discounts tohospitals that have implemented risk reduction measures,forward-thinking insurers know that small investments in safetytoday can reap significant future rewards.

Although any change in moving newly released over-the-counter (OTC)medications to benefit designs or formularies is currently beingdriven by health plans, other emerging market factors willinfluence how plans and employer groups think about coverage forOTCs. For example, Blue Cross and Blue Shield of Minnesota has hadnumerous inquiries about OTC coverage, usually from employer groupsthat know Medicaid and some Part D plans can cover OTCs. Inaddition, some states are evaluating their pharmacy practiceguidelines to determine how to revise them to accommodate changesin dispensing OTCs. This change is driven by the addition of OTCsto formularies and by the move to put pseudoephedrines behind thecounter. Another industry trend in some states, includingMinnesota, allows pharmacists to prescribe OTC products for publicprogram recipients.

Privatization of Medicare Part D has led to the emergence of manyplayers, both large and small. Navigating CMS regulations andsubsequent guidance has resulted in some administrative burdens, aswell as the inability to employ many managed care techniques, sayexperts.

Washington, D.C.-The Federal Trade Commission is concernedthat pharmaceutical companies increasingly are paying makers ofgeneric medications to delay marketing competitive products. FTCCommissioner Jon Leibowitz criticized "reverse payment"settlements, which involve compensation from a branded manufacturerlinked to restrictions on the marketing by a generic product'smanufacturer until closer to the expiration of an innovator'spatent.

Washington, D.C.-Insurers, pharmacists and Medicare officialshave established a formal partnership called the Pharmacy QualityAlliance (PQA) to improve measurement of pharmacy performance. Amajor function of the alliance will be to develop quality measures,new payment models and information systems to promote appropriatedrug treatment and to compensate pharmacists for supporting theseefforts.

More than 106 million American adults have borderline or high lipidlevels, which places them at increased risk for heart disease. Whenrecommended changes in diet and exercise do not sufficiently lowerhigh cholesterol levels, national medical guidelines call for theuse of lipid-lowering drugs.