Utilization Management the New Wave in Drug Benefits
Henahan, Sean, Drug Topics
Pharmacists can expect to see a major paradigm shift in the way drug benefits are administered and managed, predicted W. Gary Erwin, Pharm.D., senior director, pharmaceutical care management, Philadelphia College of Pharmacy and Science.
This new paradigm will shift the current emphasis on acceptability of care to that of effectiveness of care. The tools to bring this about will include utilization management programs with a strong emphasis on sophisticated computer-based management information systems, Erwin told a session of the American Managed Care & Review Association's annual Managed Care Conference in San Diego.
"Utilization management is an evolving trend which is being developed to help cope with the rising expenditures associated with pharmaceutical benefits. It provides a challenge to traditional medical and pharmacy practice in the United States. Utilization management offers a practical and effective new strategy for managing pharmaceutical benefit programs," he reported.
Numerous factors are combining to drive up the cost of drug benefits in the United States. These include the demographics of the aging population, treatment advances, drug price inflation, and federal cost shifting.
"We can't stop the population from getting older and developing diseases associated with aging. However, we can address issues such as treatment advances and 'newer is better,' as well as drug price inflation and cost shifting, through utilization management," said Erwin.
Utilization management is a proactive, integrated strategy that focuses on quality improvement and cost control. This approach recognizes the importance of pharmaceutical therapy and seeks ways to manage benefits by emphasizing appropriateness of care, he explained.
Establishment of clinical guidelines is a primary component of utilization management. In the context of a managed benefit, these guidelines would define optimal care for a variety of chronic conditions for which there is some consensus on treatment.
Utilization of antihypertensive agents offers a good example of one area in which a proactive approach that focuses on medical and cost effectiveness rather than medical acceptability could be significant, he noted. Until recently, any of 10 drugs was considered acceptable, and the pharmacist had nothing to say about it. This is no longer the case. For example, he said, data from the recent JNC5 studies led to the recommendation that cheaper diuretics and betablockers be used as initial therapy for hypertension, reserving more expensive agents for more difficult cases. …