Pharmacy

The influenza immunization rate is a closely watched HEDIS measure among plans. Influenza vaccine is about 80% effective in preventing infection in general, although its effectiveness is lower in the elderly. In addition, its effectiveness can vary from year to year, depending on the match between the vaccine and the particular strains of influenza circulating that year.

Recent studies on diabetes control are wrangling for attention with some confirming the National Health and Nutrition Examination Survey (NHANES), which suggests that diabetes control declined through the late 1990s, while others indicate that diabetics are maintaining better control.

Skyrocketing pharmaceutical costs. A still-evolving Medicare prescription drug coverage program. An influx of generic drugs. The prescription drug arena was characterized by a host of complex issues in 2006 that are certain to carry over into 2007. Managed Healthcare Executive tapped a panel of pharmacy experts to discuss big-picture issues in the United States.

The emergence of pharmacy benefit management companies (PBMs) as major players in drug benefit design and pricing has generated criticism as well as praise. PBMs previously served as drug benefit administrators for employers and other payers. But as sponsors of Medicare Prescription Drug Plans (PDPs), they now assume risk and design coverage and payment options.

National Reports-The Big Three (Wal-Mart, Target and Kmart) national retailers' generic drug discount programs highlight the increased concerns over the rising cost of pharmaceuticals, say industry experts.

Every organization is accountable to its stakeholders, and Caremark, the Nashville-based pharmacy benefit manager, is no exception. Caremark, however, is also accountable to its customers for clinical execution, so performance metrics are both wide and deep.

Recent data supports the success of Prescription Drug Plans (PDPs) under Part D.

Medication therapy management (MTM) has long been a part of the pharmacy lexicon and is based on the premise that the right medication in the right dose gets to the right patient. This is to ensure that optimal outcomes are achieved with the highest safety. Numerous examples of pharmacy programs in diverse settings utilize the skills of the pharmacist to optimize drug therapy and improve outcomes and assure safety. The Veterans Administration, academia, health plans, as well as community pharmacies have all been settings where medication management of the patient has occurred.

Washington, D.C.-The anticipated shakeout in Part D plans is not occurring this year. In fact, insurers and pharmacy benefit managers (PBMs) are offering more drug coverage options at lower costs for seniors.

Heartfelt sympathies to any of you who at this moment are holding a fistful of soggy tissues and cough drops as you read.

With about 2,000 genes now identified and more than 4,000 diseases caused by genetic defects, genetic screening is gaining ground. As it grows in acceptance by providers, patients and insurers, pharmacogenomics-the study of how one's genetic inheritance affects the body's response to drugs-is evolving. People will be able to determine if they are predisposed to a certain disease, and they will be able to find customized drugs adapted to their personal genetic makeup.

Insurers are evaluating the costs and benefits of generic testing to determine their level of commitment to the emerging medical discipline.

The growth in high-cost injectable and infusion therapies for the treatment of chronic illnesses is a significant management issue for pharmacy benefit managers and payers, experts say.

Clever approaches can help patients adhere to drug regimens, and managed care organizations are increasingly adopting the technologies that enable those approaches.

The Services provided by PPO plans are influenced by a number of factors, say industry watchers.

One in three (33%) U.S. adults who have been prescribed drugs to take regularly report that they are often or very often not compliant with their medications.

National Reports-Some recent media reports have indicated that the Medicare drug benefit has been responsible for increased earnings for pharmaceutical companies and increased membership for health plans. That may or may not be the case, say industry watchers.

National Reports-As major brand drugs such as Zocor (Merck) and Zoloft (Pfizer) lose patent protection and become available as generics, health plans, employers and patients alike can expect to realize significant savings in the long run, experts say.

Washington, D.C.-The battle between pharmaceutical companies and generics makers is heating up, this time over increased moves by brand-name firms to put out their own low-cost "authorized" generic products. While this strategy undercuts the innovator's price, it probably hurts generics firms even more by greatly diminishing the value of the 180-day exclusivity period for the first generic to market.

Heart failure is a serious condition in which the heart doesn't pump enough blood throughout the body. It may be caused by several different diseases that damage or overwork the heart muscle; the leading causes include coronary artery disease, high blood pressure and diabetes.

Medicare part D has put a new face on pharmaceutical benefits for seniors-even with all the glitches and challenges of implementing the largest social welfare program in 40 years. It welcomed 11.5 million Medicare beneficiaries prior to the May 15, 2006, deadline, according to final Medicare prescription drug benefit enrollment data.

Hospitals are ramping up efforts to improve their medication data collection methods in an attempt to reduce the number of preventable adverse drug events that occur annually. They are establishing guidelines for collecting complete drug and allergy histories and comparing those histories with new medications when patients are admitted to a hospital.

NATIONAL REPORTS-The San Francisco health access plan raises challenges for MCOs, say industry experts.

WASHINGTON, D.C.-There's new evidence that ready access to medications can reduce overall healthcare spending. A study of California Medicare beneficiaries who had a $1,000 annual cap on drug coverage finds that they spent less on drugs, but more on emergency care and hospitalizations. And they had a higher death rate compared with seniors with unlimited drug coverage.

Appropriate benefit design-copay structures and tiers-is an important factor in providing members and patients with access to treatment that is affordable. Meanwhile, cost sharing with consumers continues to increase because of pressures on maintaining competitive premium costs and the lack of innovative means to manage utilization, say experts.

The rhetoric is heating up as health insurers and pharmacy benefit managers (PBMs) try to fend off an escalating attack from retail pharmacists about late or lost payments. Delayed payments are "simply profits these giant corporations will pocket," says National Community Pharmacists Assn. CEO Bruce Roberts. "The PBM industry adds no value to the healthcare delivery system."

BLOOMINGTON, MINN.-Some preventive services contribute more to improving health compared with other preventive services, while others offer more value for the dollar, according to a recent study.

Dose consolidation is getting mixed reviews as a cost-cutting strategy according to pharmacy benefits managers (PBMs). While a study by St. Louis-based Express Scripts indicates that savings opportunities are limited, other PBMs have realized more value. With prescription drugs accounting for 10% of total healthcare expenditures, according to the California Healthcare Foundation's third "Health Care Costs 101" report, a variety of strategies are worth exploring.

The blockbuster drugs of the 1990s came off patent, became generic,and now several of them have become available over-the-counter(OTC). Others are expected to join the ranks in the next few years.This shift, combined with the increasing focus on electronicmedical records (EMRs) for longitudinal patient medication profilesand continuing pressure on the healthcare industry to take costsout of the system, drives the following questions for health plans,employer groups and pharmacy benefit managers (PBMs): Should OTCdrugs be covered by a pharmacy plan? Is benefit design sufficientfor covering OTCs and monitoring therapeutic compliance? Shouldpharmacy and therapeutic (P&T) committees modify theirformularies to be OTC-aware, or should they actually include OTCson the formulary? If a plan does incorporate OTCs into theformulary, what are the criteria for inclusion or exclusion?

There is no question in anyone's mind that the increased use of high-tech diagnostic imaging has significantly improved the diagnosis and treatment of patients during the past decade.