P&T Digest: Pain Management

Randall P. Brewer, MD, Chief Medical Editor

Chronic pain is a significant public health issue in the United States and an important concern for MCOs. Untreated or undertreated pain can evolve from a symptom to a chronic condition in its own right, one that has serious comorbid, economic, and quality-of-life consequences. As scientific understanding of the mechanisms involved in chronic pain increases, so too does the opportunity to manage affected patients in a cost-effective manner.

This peer-reviewed digest discusses the clinical and economic implications of chronic and acute pain, current guidelines for treatment, therapeutic approaches to care, and patient-management strategies. It also discusses legal and clinical considerations of opioid and nonopioid therapies for adult and geriatric populations. In consolidating the state of the art about this increasingly important subspecialty of medical care, this is a valuable tool for physicians and other clinicians, managed care clinical executives, and P&T committee members.


  • Addressing Pain Management Challenges in Managed Care
  • Conceptualizing Pain and Improving Pain Diagnosis and Assessment
  • Prevalence and Economic Implications of Chronic Pain the United States
  • Guidelines for Pain Management
  • Balancing Patient Needs and Provider Responsibilities in the Use of Opioids
  • Delivery Systems: Advantages and Disadvantages
  • Benefits of Pain Management in the Elderly
  • The Value of Multidisciplinary Care

Managed Care Best Practices in the Treatment and Management of Non-Small Cell Lung Cancer

Lung cancer is the most prevalent form of cancer-related mortality in adults. Because the diagnosis of lung cancer at an advanced stage generally has a poor prognosis, lung cancer must be diagnosed early and treatment options must be expanded. Non-small cell lung cancer (NSCLC) accounts for 80 percent of all cases and has been treated through chemotherapy, radiation therapy, combined chemoradiotherapy, and surgery. Increasingly, combining emerging biologic and experimental therapies with conventional treatments holds the potential for favorable outcomes. This supplement summarizes the growing number of treatment options available.


    • Non-Small Cell Lung Cancer – an Overview
    • Outlook for Non-Small Cell Lung Cancer Treatment
    • Treatment Options – a Medical Director’s Perspective

Panel Discussions:

    • Improving Survival and Quality of Life
    • Benefit and Reimbursement Structures for Oncologics
    • Fostering Appropriate Use of Oncologics

Considerations in Creating a Medicare Part D Formulary

Access to medications is the key concern of every stakeholder in the Medicare Part D outpatient drug benefit. Beneficiaries want increased access that will reduce out-of-pocket expenses. Prescription drug plans want to control access so as to assure the financial viability of their programs. Medicare Advantage plans want to promote access as a means to reduce hospitalizations and other expenditures. This supplement examines the variables to consider when constructing a Part D formulary.


    • Strategies for Developing a Successful Medicare Part D Formulary
    • Case study: Antidementia agents
    • Case study: TNF inhibitors
    • Case study: Bisphosphonates

Improving Quality by Encouraging Providers To Use Pediatric Combination Vaccines

It is not every day in the health care business where an investment of $1 results in savings of more than $18. There is solid evidence to support widespread pediatric vaccinations, especially combination vaccines, to achieve such cost saving. Goldfarb and colleagues analyze the promotion of pediatric combination vaccines in a managed care setting and make recommendations to improve our current performance.


    • Use of Combination Vaccines To Improve Immunization Coverage Rates and Timeliness of Administration
    • National Recommendations From the Centers for Disease Control and Prevention on Combination Vaccines
    • Potential Effects of Combination Vaccines on Quality and Cost
    • Barriers to Broader Use of Combination Vaccines
    • Managed Care Strategies To Improve Utilization of Combination Vaccines

Obstructive Lung Diseases — Asthma and COPD: Managing the Patient and the Costs

Obstructive lung diseases represent a serious financial and resource burden for MCOs. Correctly diagnosing and treating these patients has proven difficult because of limited testing, the potential for presenting with concomitant diseases, and the similarities among diseases. Making an early and accurate differential diagnosis is essential to proper and cost-effective treatment of these patients. This publication reviews current guidelines for treatment, challenges related to proper diagnosis, and benefits of early treatment.


  • The health plan’s perspective on care management
  • Clinical perspectives on obstructive lung disease
  • Treatment guidelines and performance indicators
  • Burden of illness in Medicaid and managed care populations

Undertreatment of Depression and Comorbid Anxiety Translates Into Costly Mismanagement of Resources and Poor Patient Outcomes

According to the literature and measured against national standards for quality of care, treatment of depression is substandard. MCOs that frequently adopt step therapy to reduce pharmacy budgets might do well to re-examine those programs in light of the overall medical cost to the system and the quality of care that those patients receive. This publication explores ways in which providers, payers, and employer purchasers can contribute to an overall improvement in quality of care.


  • Why, and to what extent, depression and comorbid anxiety are underdiagnosed and undertreated in our society
  • How HEDIS tracks and documents substandard treatment
  • What major stakeholders can do to improve care and outcomes for patients with depression and comorbid anxiety
  • The clinical and economic importance of compliance with medication therapy
  • National trends in the pharmaceutical treatment of anxiety

Managed Care Best Practices in the Treatment and Management of Asthma

Asthma is a syndrome, not a single disease, with multiple phenotypes. Much concerning poor outcomes with asthma treatment is related to misdiagnosis or underdiagnosis, inadequate prescribing of preventive therapy, and poor adherence to treatment plans. Recent advances in our understanding of the variable and syndromic nature of the disease have led to the possibility of improved and more individualized care pathways, which will increase the likelihood of successful outcomes for the patient, society, and the health care system. A focus on asthma control, rather than severity, likely will allow for more accurate monitoring of outcomes and improved care delivery.


  • The Burden of Uncontrolled Asthma on the U.S. Health Care System
  • Challenges in Evaluating and Treating Asthma
  • The Importance of Risk Assessments
  • Managed Care Strategies for Successful Asthma Management
  • Controlling Asthma Through Disease Management

Mobilizing Efforts in Osteoporosis Management

The number of Americans age 65 and older will more than double by the year 2050. This cohort will include 20 million people 85 and older — potential osteoporosis patients who today are between 25 and 45 years old. Although past their prime bone-building years, they are not yet candidates for bone-density tests or drug therapy. Many should never need these interventions — provided that low-cost preventive strategies are implemented, starting now. Sound health care policy is directed toward ensuring that negative trends are not allowed to continue unchecked. This supplement is intended to achieve that end.


  • Current and Emerging Treatment Options
  • Identification of Patients at High Risk for Fracture
  • Implications of the Medicare Modernization Act for Care of Osteoporosis Patients
  • Managed Care and Best Practices

The Future of Public Health

Today’s public health system addresses an array of challenges, including chronic diseases, mental health, substance abuse, traumatic injuries, environmental and occupational health, and bioterrorism. This supplement, based on a symposium at the University of the Sciences in Philadelphia, features national experts in public health who contend that increased life expectancy is leading us to a convergence of scientific, demographic, and economic forces that could lead public health to preempt clinical medicine as the primary focus of American health care.


  • Public Health: Community and a Shared Future
  • Which Road Will Public Health Take?
  • Funding and the Mechanisms of Change
  • Preventive Care: The First Step
  • Panel Discussion: Keeping Americans Healthy and Safe

How Can Medical Directors Have the Greatest Impact on Quality Improvement?

This supplement derives from the 2005 Medical Director Colloquy, an interactive forum between top medical managers and an expert faculty comprising medical and business professionals. Addressing the general issue of quality improvement, this supplement presents an argument supporting employers’ increased involvement in workplace health-promotion programs, use of quality-of-care indicators, and ways in which information technology can be used to obtain greater value from current U.S. health care expenditures.


  • Digital Medicine and the Managed Care Medical Director
  • A View of Preserved Systolic Function and the Approach to the Heart Failure Patient
  • Multiple Benefits of Bariatric Surgery
  • Evolving Perspectives on Disease Management
  • Better Outcomes Through Health and Productivity Management
  • Quality of Care: Where Do We Go From Here?

P&T Digest: Asthma

Michael A. Kaliner, MD, Chief Medical Editor

Asthma is one of the most common illnesses in the United States and a major driver of health care utilization costs. It also can be a challenge to manage. Disease severity, as defined by guidelines, does not necessarily correlate with patients’ self-reported symptoms, meaning that vigilance is imperative to reducing poor outcomes.

This peer-reviewed digest of current and evolving guidelines for treatment, existing and emerging therapeutic approaches to treatment of depression, and strategies for managing patients and their conditions, is a valuable tool for physicians and other clinicians, managed care clinical executives, and P&T committee members. Its chapters discuss asthma as a disease syndrome, unmet medical needs, its burdens on society, and what can be done to alleviate those burdens.


  • Controlling Asthma: A Persistent Liability
  • Prevalence and Economic Implications
  • Addressing Unmet Needs in Asthma Care
  • Treatment Guidelines: Current Recommendations, Future Goals
  • Drug Treatment for Long-Term Control of Asthma
  • New Developments in Asthma Therapy
  • Adherence With Asthma Therapy
  • Disease Management Considerations in Asthma
  • HEDIS Requirements and Considerations With Asthma

Advances in Treatment and Management of Early Breast Cancer

Tamoxifen has been the mainstay of adjuvant drug treatment aimed at reducing the risk of recurrence of breast cancer. Yet, in light of new information about the utility of aromatase inhibitors as adjuvant therapy, such as that provided by the Arimidex, Tamoxifen, Alone or in Combination (ATAC) study, oncologists may have more options. Early indications are that, in comparison with tamoxifen, aromatase inhibitors increase disease-free survival for postmenopausal women with hormone receptor-positive early-stage breast cancer.


  • Breast Cancer: An Overview of the Disease
  • Advances in Systemic Treatment of Early Breast Cancer in Postmenopausal Women
  • Managing Treatment of Early Breast Cancer in Postmenopausal Patients: A Nurse Practitionerís View
  • A Medical Directorís Perspective on Early Breast Cancer

Pay for Performance: Opportunity and Challenge for Improving Health Care

Pay for performance has emerged as a key issue in health care, generating discussion, anxiety, and a vigorous exchange of ideas. This supplement, derived from the 11th annual Department of Health Policy Summer Seminar at Thomas Jefferson University, features presentations from Andrew Webber, president and CEO of the National Business Coalition on Health, Dennis Scanlon, PhD, associate professor of health policy and administration at Pennsylvania State University, and Margaret Van Amringe, director of the Joint Commission on Accreditation of Healthcare Organizations.


  • Building a Business Case for Better Health Care
  • Evidence for Pay for Performance
  • Developing an Effective Pay-for-Performance Program