Expect Close Encounters With Pharmacy’s Third Tier

Pharmacy in managed care has edged its way forward as a major issue of the day, thanks in part to the long-overdue discussion of whether (and/or how extensively) to provide drug coverage for people in the Medicare program. The fact is, we rely increasingly on pharmacy to deal with health care problems and to forestall greater costs in other components of the system, such as inpatient services and emergency rooms.

Pharmacy coverage should not be decided separately from overall health coverage. Everyone who has medical coverage (which should be everyone, though heaven knows, we’re a long way from there and the road is rocky — see our TennCare report) should have drug insurance. Not providing it is like not providing surgical coverage: “Need a CABG? You’re on your own, Jack.”

As usual, the devil is in the details. Senior Editor Michael D. Dalzell lays out a lot of those details in our cover story, “The Double-Edged Sword,” which describes the difficulties in devising a copayment scheme that will simultaneously control costs by preventing waste and enhance health by promoting adherence (formerly compliance, a word that seems to have been reassigned to the Office of Inspector General). To my mind, this is one of the most vexing problems in managed care today, and while a strategic approach is what’s needed, most plans, reacting to steep increases in pharmacy costs, are making tactical moves that may not get at the roots of the problem.

Many people are giving this issue serious thought, and one of the most respected is J. Lyle Bootman, Ph.D., the new president of the American Pharmaceutical Association and the subject of our popular Question & Answer feature. That the professional pharmacists association has chosen an economist as its 1999 leader shows that the profession as a whole — and not just its managed care component — is attentive to the interaction of cost and care.

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