Managed Care Pharmacy

A collection of articles from MANAGED CARE magazine


Managing the Drug Benefit: One Company’s Experience
The pharmacy director of Blue Cross of Oklahoma shares his company’s success with using three tiers and coinsurance to promote member responsibility. [July 2002]

Third-Party Payers Don’t Realize Burdens Placed on Pharmacists
PBMs and HMOs, by imposing a workload that doesn’t allow enough time for needed functions, seem to want pharmacists to fail, this author asserts. [June 2002]

HMOs Should Prepare Now To Get Handle on Injectables
With more than 360 biotech products in the pipeline, high-cost injectable drugs are about to flood the market. How will we control the expenditure? [April 2002]

HMOs Have Stake in Quelling Anger at Drug Store Counters
Dissatisfied customers have a tendency to lash out and not be very discriminating about their targets. Prescription: Reduce the hassle. [April 2002]

A Conversation With Alan T. Wright, MD: He Wants AdvancePCS to Manage More Than Drugs
The CMO of the nation’s largest pharmacy benefits manager says that the company’s mission has broadened. One new area of focus: worker productivity. [March 2002]

Proposal To Regulate Formularies Draws Sharp Difference of Opinion
The National Association of Insurance Commissioners has spent two years developing a model. Drug companies like it; health plans don’t. [February 2002]

Reframing the Pharmaceutical Manufacturer/Health Plan Relationship in Managed Care
To the degree health plans start building sophisticated, long-term strategic partnerships with pharmaceutical manufacturers into their business models, managed care will gain the capacity to advance beyond its vendor stage and make good on its original mission of promoting preventive health, improving individual outcomes, and realizing sustainable cost containment. [February 2002]

E-Prescribing Gets More Enticing
Hand-held computing devices are hot technology in medical practice due to the confluence of several factors. First, managed care organizations actively have worked to affect the drug-prescribing behavior of primary care physicians. [February 2002]

A Health Care Management Company’s Experience with Palivizumab
By appropriate application of criteria for the use of palivizumab, a significant amount of money ($6,000 per case) can be saved while at the same time demonstrating no additional risk to the patient. [January 2002]


Increased Pressures Change P&T Committee Makeup
Formulary committees once were stocked with academics and administrators. Today, primary care physicians, specialists, and retail pharmacists play a bigger role, and tomorrow’s membership will be even more diverse. [December 2001]

PBM Industry Today: Who’s Managing Drug Costs?
Health plans need to take a closer look. HMOs and employers alike will feel increasing pressure to give in to the desires of consumers. [December 2001]

Q&A; with John A. Gans, DrPh: Some Over-the-Counter Advice On Making Drug Therapy Work
The executive vice president and CEO of the American Pharmaceutical Association says pharmacists are being inundated and need help. [October 2001]

Q&A with Judith Cahill: The Expanding Role of Pharmacists
Lobbying in Washington, monitoring state legislation and generally looking out for the interests of pharmacy programs run by health care plans and pharmacy benefit managers, Judith Cahill leads the AMCP at an exciting, critical time. [August 2001]

Wide variation in pharmacy utilization
Charts. On a per-capita basis, prescription drug use in the U.S. is generally highest in the South and Midwest, and lowest in four states with high managed care penetration — California, Massachusetts, Colorado, and New York. These per-member, per-year utilization averages are based on an analysis by Express Scripts, the pharmacy benefit manager, of its commercial population in 2000. [September 2001]

Four-Tier Approach Injects Consumerism Into Drug Benefit
In tying copayments closely to the actual cost of medications, Humana takes a step toward promoting awareness of resource use. [August 2001]

Compensating the pharmacy services manager
Charts. One of the positions that Warren Surveys looked at when it tracked the salaries of 266 titles at over 500 HMO and managed care companies was pharmacy services manager. Here is what pharmacy service managers are paid in different areas of the country at different-sized health plans. The salaries are based on data collected as of Feb. 1, 2001. [July 2001]

Oregon Attempts To Blaze Trail With ‘Reference-Based’ Formulary
Pharmaceutical makers invest enormous sums in R&D – but they also reap enormous profits. States are impatient with the appearance that creates. [July 2001]

Genetic Medicine: Powerful Opportunities For Good and Greed
Genetic advances could spawn incredible improvements in health care. Given public demand, they also pose what may be unmanageable issues of resource use. [May 2001]

Q&A with Alan F. Holmer: “Terms of Coverage for Elderly Top Priority for Drug Industry”
With the ever-rising cost of prescription drugs generating an outcry to reform Medicare, PhRMA’s president finds himself in the eye of the storm. [April 2001]

System Helps P&T Committees Get Pharmacoeconomic Data They Need
The Academy of Managed Care Pharmacy is testing a plan to have drugmakers submit evidence-based outcomes analyses when seeking formulary inclusion. [April 2001]

New Spin on Risk Assessment Demonstrated as Cost-Effective
The authors argue that this method can enhance patient care by improving provider awareness, resulting in millions of dollars in savings. [March 2001]

Persistence With Drug Therapy: A Practical Approach Using Administrative Claims Data
The Estimated Level of Persistence with Therapy (ELPT) approach that will be discussed here makes efficient use of valuable information that is already available within administrative pharmaceutical-claims databases. The ELPT provides an inexpensive, unobtrusive way to determine the extent to which patients are filling their prescriptions for long-term therapies or treatments for chronic disease on a regular basis. While the analysis of this information does not reveal whether a pill is actually being ingested, it can be reasonably assumed that patients would not continue to refill a prescription without the intention to adhere. [February 2001]

Making Pharmacoeconomics In Formulary Development a Reality
Despite what might be commonly believed, pharmacoeconomics is not a widely used tool for formulary development. Here’s a model to follow [February 2001]


Prescription Drug Reimportation: Panacea or Problem?
Health plans concerned about the cost of pharmacy benefits might want to look at potential effects of prescription drug reimportation — formulary issues and legal questions, to name two — even if full implementation is a while off. [December 2000]

Physicians Reconsider Taking On Pharmacy Risk
They’ve been burned here in the past, but physicians – and the HMOs that they contract with – may have learned some lessons. [July 2000]

WASHINGTON WATCH: Broad-Based Coalition To Study Effectiveness of New Pharmaceuticals
Where prescription drugs are concerned, does new necessarily mean better? And what’s the role of the federal government where the pharmaceutical industry is concerned? Research by a new coalition may yield some answers about what’s driving increased demand — particularly, why more Americans are using more prescription drugs at earlier ages — and in turn, could set the stage for public policy considerations. [June 2000]

STATE INITIATIVES: Northeast States Pursue Price Controls To Stop Rise in Prescription Drug Costs
“The high cost of prescription drugs is a crisis,” says Maine Senate Majority Leader Chellie Pingree. “Working people tell us they make a difficult choice between filling their prescription or buying food or heating oil — or, in many cases, going broke.” [May 2000]

STATE INITIATIVES: State Insurance Commissioners Weigh PBM Regulations This Month
“As far as I know, PBMs aren’t under anyone’s jurisdiction,” says NAIC Vice President Kathleen Sebelius, the Kansas commissioner of insurance. “All of us are carefully watching pharmacy costs and their threat to health plan solvency, and the ability of small employers and others to offer health insurance. Whether it’s appropriate for regulators to have oversight, control, or licensing jurisdiction over PBMs will be a logical part of this discussion.” [March 2000]

Test Prospective PBM Before Signing Contract
How to select, then monitor a pharmacy benefit management company, from a consultant and former HMO director of pharmacy services. [March 2000]

WASHINGTON WATCH: Regulators, Congress Seek To Cast Tighter Net Over Online Pharmacies
Using the Internet to purchase prescription drugs is increasingly popular, but some government regulators and managed care professionals say it can also be dangerous. The U.S. Food and Drug Administration argues that electronic commerce can bypass or undermine the safeguards offered by direct medical supervision. [February 2000]



Direct-To- Consumer Advertising: Can Everyone’s Interests Be Balanced? (Cover story)
Cost pressures that plans associate with rising drug expenditures result partly from their own largesse. Solutions: Restore consumerism and forge a common agenda with drug companies. [December 1999]

Pharmacy Copayments: A Double-Edged Sword (Cover story)
Health plans hope to rein in utilization by raising pharmacy copayments. Whether the scheme works or backfires depends on how it’s implemented. [August 1999]

Q&A: A Conversation With J. Lyle Bootman, Ph.D.
The new president of the American Pharmaceutical Association foresees greater cooperation between pharmacists, physicians, and health plans. [August 1998]

Potential for Profit, Potential for Real Change
Now, online outlets are alternate retail sites. But if they can help physicians and plans solve medication compliance problems, they will be formidable. [July 1998]



OUTLOOK: To get or to skip care?
Not surprisingly, many uninsured adults either do not get or postpone care they need. [December 1998]

ETHICS: Code Could Be Right Prescription to Give Pharmacy More Credence
A pharmaceutical code of ethics — if it were ever hammered out — would have to arise from a detailed examination of the industry’s vision, mission and principles. [December 1998]

Q&A: A Conversation with Michael J. Dillon, R.Ph.
The executive director of the Foundation for Managed Care Pharmacy speaks of the challenge of reining in escalating drug costs. [November 1998]

OUTLOOK: ‘I want what I want, or I’m outta here’
Pharmacy issues may greatly affect members’ perceptions of their health plans, suggests a survey of 38,000 enrollees who requested prescriptions for specific drugs. [November 1998]

We Have the Tools for Safer Prescribing and Dispensing
Although there aren’t any perfect solutions to creating a formulary free of drug-drug interactions, there are things you can do to limit problems. [September 1998]

Data Access Technology Puts Physicians Under Microscope
A medical director’s casual ruminations suggest that HMOs watch primary care doctors not out of malice, but with a true desire to help. [August 1998]

Does Mail-Order Pharmacy Really Deliver the Goods?
There’s a low-key war going on between community pharmacies and the big guys that offer drugs by mail. Is this about money or medicine? [June 1998]

The Pitfalls and Potential of Pharmacy Risk
Prescription benefit arrangements between physicians and managed care companies seem to be a growing trend replete with growing pains. [May 1998]

Getting Serious About Formularies
Many physicians think narrowing the universe of available drugs from an estimated 8,000 to around 1,200 is a pretty serious change in health care. Yet the formulary system persists and is spreading widely. [March 1998]

Is ‘Pharmaceutical Care’ A Problem or Panacea?
As pharmacists expand their patient care roles, health plans and physicians differ in their responses. Both have sound arguments. [February 1998]

OUTLOOK: What’s behind increases in pharmaceutical spending?
A dramatic increase in pharmaceutical expenses contributed to HMOs’ less-than-stellar financial performances during the last two years. [February 1998]



Having Pharmacists Review Drug Regimens Could Save Billions
Medication-related health problems afflict many patients and waste billions of dollars in treatment. Consultant pharmacists say they can help, and now have figures to back up their claim. [December 1997]

Formularies get stricter
Pharmaceuticals may be a modest piece of the health care pie, but modest doesn’t mean insignificant. HMOs and pharmacy benefit managers, often working together, continue to put pressure on physicians to prescribe, and pharmacists to dispense, certain drugs. [August 1997]

Cut Pharmaceutical Costs, But Mind the Legal Dangers
Health plans and physicians have every right to hold down the cost of pharmaceuticals, as long as patients aren’t harmed. But not everyone agrees on what actions are acceptable. [August 1997]

High-Tech Drug Packaging Can Boost Patient Compliance
Sometimes you have to spend money to save money. Vials with microchips, beeping blister packs and other new pharmaceutical delivery media, even if they are a bit pricey, could lower overall health care costs. [June 1997]

Utilization of Generics: A Managed Care Failure?
Managed care is in the business of holding down costs. Generics cost less than brands. But there are many pressures from patients, physicians — even employers — to stick with the branded products. [May 1997]

Reinventing the PBM
Having transformed the market, pharmacy benefit management companies are now in for some shaking up themselves. More tightly controlled formularies are one possibility. [April 1997]

Getting ACE Inhibitors Into the Right Hands
We know that ACE inhibitors are a front-line treatment for congestive heart failure, but they’re not prescribed often enough. Will managed care give physicians a nudge? [January 1997]



EMPLOYER UPDATE: Union Carbide Uses Education To Improve Patient Compliance
To improve compliance among its own employees and retirees, Union Carbide Corp. recently launched a pilot program with Aetna U.S. Healthcare to make sure employees are well informed about their medications. [November 1996]

Get Ready! Electronic Prescriptions Are Coming
Technology that allows you to zap prescriptions to pharmacies instantly is already being used by some doctors. Are you willing to discard your pen and pad for a computer that can send electronic prescriptions? [August 1996]

Next HMO quality hurdle: integrating medical and pharmacy data
A recent survey of pharmacy directors in 49 HMOs representing 9.5 million enrollees revealed that most of the plans have now embraced “disease state management” programs. [August 1996]

The Compliance Challenge In Treating Helicobacter Pylori
It’s all well and good to know that H. pylori causes peptic ulcer disease. But putting this knowledge to work curing ulcers–and saving money–means making sure the patient actually takes the pills. [April 1996]

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