Effects of a 3-tier pharmacy benefit design on the prescription purchasing behavior of individuals with chronic disease.
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OBJECTIVE: To evaluate the impact of 3-tier (copayment) pharmacy benefit structures on medication utilization behavior. METHODS: A pretest-posttest quasi-experimental design was employed. Chronic disease sufferers (N=8,132) from a health plan were classified into the following groups: (a) 2-tier copayment moving to a 3-tier structure, (.converting. group), (b) 2-tier staying in a 2-tier structure and, (c) 3-tier staying in a 3-tier structure. The latter 2 were.comparison. groups. Two 7-month time periods were determined: the.preperiod. (June through December 2000) and the.postperiod. (January through July 2001) for a change in pharmacy benefit structure. Pharmacy claims data were used for data collection. Statistical analyses included bivariate tests to evaluate predifferences and postdifferences across study groups. Maximum likelihood estimates from a repeated measures model were used to examine changes in formulary compliance and generic use rates. Discontinuation of nonformulary medications was evaluated using logistic regression. RESULTS: Controlling for demographics, number of comorbidities, disease state, and pharmacy benefit structure, the formulary compliance rate increased by 5.6% for the converting group. No significant increases were seen for the comparison groups. Generic use rates increased by 6 to 8 absolute percentage points for all groups (3.3% to 4.9 % adjusted rates). Converting group members were 1.76 times more likely to discontinue their nonformulary medication than those in the 2-tier comparison group and 1.49 times more likely than those in the 3-tier comparison group. CONCLUSIONS: These findings suggest that shifting individuals from a 2-tier to a 3-tier drug benefit copayment structure resulted in changes in medication utilization. Decision makers need to balance these changes with the potential dissatisfaction that members may express in paying higher copayments. (+info)
Pharmacy benefit forecast for a new interferon Beta-1a for the treatment of multiple sclerosis: development of a first-line decision tool for pharmacy-budget planning using administrative claims data.
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OBJECTIVE: To estimate the incremental change in pharmacy per-member-permonth (PMPM) costs, according to various formulary designs, for a new interferon beta-1a product (IB1a2) using administrative claims data. METHODS: Cross-sectional sex- and age-specific disease prevalence and treatment rates for relapsing, remitting multiple sclerosis (RRMS) patients were measured using integrated medical and pharmacy claims data from a 500,000- member employer group in the southern United States. Migration to IB1a2 from other drugs in the class was based on market-share data for new and existing RRMS patients. Duration of therapy was estimated by analyzing claims for current RRMS therapies. Daily therapy cost was provided by the manufacturer of IB1a2, adjusted for migration from other therapies, and multiplied by estimated volume to predict incremental and total PMPM cost impact. Market-share estimates were used to develop a PMPM cost forecast for the next 2 years. PMPM cost estimates were calculated for preferred (copayment tier 2) and nonpreferred (copayment tier 3) formulary designs with and without prior authorization (PA). One-way sensitivity analysis was performed to assess the influence of product pricing, duration of therapy, and other market factors. RESULTS: Annual incremental PMPM change was $0.047 for the scenario of third copayment tier with PA. The incremental change was greatest for those aged 55 to 65 years ($0.056 PMPM) and did not vary greatly by benefit design. Duration of therapy had the greatest impact on the PMPM estimate across benefit designs. CONCLUSION: IB1a2 will not cause a significant change in managed care pharmacy budgets under a variety of formulary conditions, according to this crosssectional analysis of current care-seeking behavior by RRMS patients. Economic impact may differ if IB1a2 expands RRMS patients. treatment-seeking behavior. (+info)
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the pharmacy benefit: implications for health plans, PBMs, and providers.
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OBJECTIVE: To summarize and analyze the key provisions of the Health Insurance Portability and Accountability Act (HIPAA) and the impact on pharmacies, health plans, pharmacy benefit managers, and others involved in the delivery of pharmacy services and managed pharmacy benefits. BACKGROUND: HIPAA was enacted by Congress in 1996 with the goals of administrative simplification in the health care system as well as protecting the privacy of individuals. HIPAA imposes new standards for health care transactions and patient privacy and defines new patient rights regarding their health care information. Transaction standards took effect October 16, 2002, while the privacy standards have a compliance date of April 14, 2003. Regulations, or.standards,. will apply to health plans, pharmacies, and other health care providers and other businesses involved in the delivery of health care services. Failure to comply will be punishable under the law. The U.S. Department of Health and Human Services estimated the 10-year cost of compliance to be $17.6 billion US dollars. CONCLUSION: HIPAA's new requirements will demand significant effort and expense for systems and business process development. Businesses from the smallest independent pharmacy to the largest health plans must be compliant by the deadlines imposed by HIPAA. (+info)
Evaluation of personal digital assistant drug information databases for the managed care pharmacist.
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BACKGROUND: Personal digital assistants (PDAs) are becoming a necessity for practicing pharmacists. They offer a time-saving and convenient way to obtain current drug information. Several software companies now offer general drug information databases for use on hand held computers. PDAs priced less than 200 US dollars often have limited memory capacity; therefore, the user must choose from a growing list of general drug information database options in order to maximize utility without exceeding memory capacity. OBJECTIVE: This paper reviews the attributes of available general drug information software databases for the PDA. It provides information on the content, advantages, limitations, pricing, memory requirements, and accessibility of drug information software databases. SUMMARY: Ten drug information databases were subjectively analyzed and evaluated based on information from the product.s Web site, vendor Web sites, and from our experience. Some of these databases have attractive auxiliary features such as kinetics calculators, disease references, drug-drug and drug-herb interaction tools, and clinical guidelines, which may make them more useful to the PDA user. CONCLUSION: Not all drug information databases are equal with regard to content, author credentials, frequency of updates, and memory requirements. The user must therefore evaluate databases for completeness, currency, and cost effectiveness before purchase. In addition, consideration should be given to the ease of use and flexibility of individual programs. (+info)
Mail-order prescriptions requiring clarification contact with the prescriber: prevalence, reasons, and implications.
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BACKGROUND: Prescription review by pharmacists prior to dispensing is an important step in an overall strategy for preventing medication errors. Contacts with prescribers may be required to clarify missing, unclear, or inconsistent information. While essential to reduce the likelihood of potential patient harm, clarification contacts are time-consuming for pharmacists and prescribers. The scope of the issue and the factors that contribute to it are not well understood. OBJECTIVE: To quantify the frequency of contacts with prescribers that were necessary to obtain clarification of prescriptions and to identify the factors that made these prescriber contacts necessary. METHODS: An analysis was conducted involving new prescriptions received by a national mail-order pharmacy that required clarification contacts with prescribers for quality reasons (i.e., those potentially impacting the accuracy of dispensing). Excluding refills and renewals, the percentage of new prescriptions requiring clarification contacts was calculated and categorized by incoming delivery channel (mail, fax, telephone, etc.). The quality problems that prompted these contacts were categorized according to the problem identified. RESULTS: Among the total of 295378 new prescription orders received during the 1-week study period (from April 7 to April 13, 2002), 8.7% contained quality problems that necessitated clarification contact with prescribers. Prescriptions received by fax transmission and mail were most likely to require clarification as compared with direct telephone conversation and miscellaneous (including electronic) channels. Among prescriptions that required a clarification contact for quality problems, an average of 2.4 problems per prescription was observed. The most common problems were: directions unclear or missing (24.3%); refill quantity unclear, missing, or incorrect (24.3%); dosage unclear (20.2%); drug name or strength unclear (13.2%); missing physician or patient data (11.4%); and missing prescriber signature (3.2%). CONCLUSION: Prescriber clarification contacts are frequently needed to reduce the potential for medication error in the current prescription fulfillment process. While these contacts are necessary to clarify data elements essential to accurate medication dispensing, they are time- and resource-intensive. These study results suggest that alternate prescription order channels, including electronic, could reduce the sizable burden of prescription order clarification in mail-order pharmacy. (+info)
Resource use and patient care associated with chronic kidney disease in a managed care setting.
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OBJECTIVE: To describe the resource utilization and care of chronic kidney disease (CKD) patients in a managed care plan. METHODS: This was a retrospective claims analysis of a nationwide managed care medical and pharmacy database from September 1, 1998, to July 31, 2001. Twenty-seven health plans in 19 states distributed across the Northeast, Southeast, Midwest, and Southwest United States were represented in this analysis. CKD patients were identified using ICD-9 CM, CPT-4, and HCPCS codes indicative of dialysis. Patients continuously enrolled for at least 6 months before and 3 months after an initial dialysis event were included in the study. Health care charges and associated clinical information were assessed during 3 time periods: predialysis was from the sixth through the second month before initial dialysis, peridialysis was 30 days before and 30 days after initial dialysis, and postdialysis was the second and third month after initial dialysis. The main outcome measures were total health care charges, primary diagnoses, and diagnosis- related groups (DRGs). RESULTS: The per-patient-per-month charges were 4,265 dollars in the predialysis period (average for 5 months), 35,292 dollars in the peridialysis period (average for 2 months), and 15,399 dollars in the postdialysis period (average for 2 months). The most common primary diagnosis categories during all time periods were chronic renal failure and congestive heart failure. Similarly, the most common DRGs were related to renal and heart failure. A total of 38.2% of patients did not have an initial nephrologist visit until the first dialysis event. Treatments with nutritional supplements and medications such as angiotensin-converting enzyme inhibitors and erythropoietin were found to be suboptimal. CONCLUSION: CKD patients generate significant medical charges during the predialysis period and after initiation of dialysis. Further investigations are warranted to assess the impact of active management of CKD patients on CKD-related health care expenditures in kidney disease. (+info)
Assessment of clinical pharmacist management of lipid-lowering therapy in a primary care setting.
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BACKGROUND: Pharmacists have been shown to positively impact the outcomes of care for treatment of many different kinds of disease states. In particular, pharmacist-run lipid clinics have enjoyed varying degrees of success, depending on the outcome assessed. At our hospital, when a patient is transferred to the pharmacist-coordinated lipid clinic, the primary care pharmacist is responsible for ordering and interpreting labs and prescribing and monitoring lipid-altering therapy. OBJECTIVE: This study was designed to assess if there is a statistically significant difference between the magnitude of serum cholesterol reduction for patients receiving lipid-altering pharmacotherapy when clinically trained pharmacists are actively prescribing and adjusting the drug therapy compared to other health care practitioners (usual care). METHODS: Patient records from the hospital computer databases were retrospectively and randomly selected for analysis. Following evaluation for inclusions and exclusions, 41 patient records remained for statistical analysis for the cohort group, and 47 records remained from the group of patients managed by a clinical pharmacist. RESULTS: Management of dyslipidemia by a clinical pharmacist was associated with a significant reduction in overall mean low-density lipoprotein (LDL, 18.5%) compared to the cohort that did not have a clinical pharmacist as the primary manager of dyslipidemia (6.5%, P=0.049). This suggests improved clinical outcomes, defined as greater LDL reduction, when clinical pharmacists participate in lipid management, including drug prescribing. The magnitude reduction in LDL was found to be related to the number of clinical pharmacy visits (11.4% for 1 visit, 23.2% for 2 visits, and 23.7% for >3 visits), compared to the usual care group (-11.0%, 18.0%, and 7.4%; statistically significant, P=0.038, for >3 visits only). These results occurred even though the group of dyslipidemic patients managed primarily by a clinical pharmacist contained a statistically greater number of patients with 2 or more risk factors and high-density lipoprotein (HDL) levels less than 40 mg/dL. CONCLUSION: Interdisciplinary medical teams that include clinical pharmacists who are actively prescribing and adjusting lipid drug therapy may achieve greater reductions in LDL for patients who have been assessed with multiple risk factors compared to patients managed without clinical pharmacists. Active participation by clinical pharmacists in lipid management for patients with elevated LDL resulted in improved treatment success as measured by the magnitude reduction in LDL. The reduction in LDL was between 5% and 22% per visit greater for patients being treated by clinical pharmacists versus usual care, even in a patient population with more risk factors. These intermediate outcomes may translate into long-term outcomes in fewer cardiovascular events, improved quality of life for patients with dyslipidemia, and lower costs associated with sequelae of dyslipidemias. (+info)
Framework for pharmacy services quality improvement--a bridge to cross the quality chasm. Part I. The opportunity and the tool.
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OBJECTIVE: To review the literature on the subject of quality improvement principles and methods applied to pharmacy services and to describe a framework for current and future efforts in pharmacy services quality improvement and effective drug therapy management. BACKGROUND: The Academy of Managed Care Pharmacy produced the Catalog of Pharmacy Quality Indicators in 1997, followed by the Summary of National Pharmacy Quality Measures in February 1999. In April 2002, AMCP introduced Pharmacy's Framework for Drug Therapy Management in the 21st Century. The Framework documents include a self-assessment tool that details more than 250 specific "components" that describe tasks, behaviors, skills, functions, duties, and responsibilities that contribute to meeting customer expectations for effective drug therapy management. FINDINGS: There are many opportunities for quality improvement in clinical, service, and cost outcomes related to drug therapy management. These may include patient safety; incidence of medical errors; adverse drug events; patient adherence to therapy; attainment of target goals of blood pressure, glucose, and lipid levels; risk reduction for adverse cardiac events and osteoporotic-related fractures; patient satisfaction; risk of hospitalization or mortality; and cost of care. Health care practitioners can measure improvements in health care quality in several ways including (a) a better patient outcome at the same cost, (b) the same patient outcome at lower cost, (c) a better patient outcome at lower cost, or (d) a significantly better patient outcome at moderately higher cost. Measurement makes effective management possible. A framework of component factors (e.g., tasks) is necessary to facilitate changes in the key processes and critical factors that will help individual practitioners and health care systems meet customer expectations in regard to drug therapy, thus improving these outcomes. CONCLUSIONS: Quality improvement in health care services in the United States will be made in incremental changes that rely on a structure-process-outcome model. The structure is provided by evidence created from controlled randomized trials and other studies of care and system outcomes that are based on the scientific method. The process portion is created by the application of evidence in the form of clinical practice guidelines, clinical practice models, and self-assessment tools such as Pharmacy's Framework for Drug Therapy Management. Incremental changes in structure and process will result in the desirable outcome of meeting customer needs for more effective drug therapy and disease management. (+info)