Pharmacy

With its first phase of certification rolling, the CertificationCommission for Healthcare Information Technology (CCHIT) willconcentrate on maintaining its momentum while moving to the realmof inpatient electronic health records (EHRs) in its secondcertification phase, followed by the evolving EHR networkinfrastructure in phase three.

Insurance companies are constantly on the lookout for innovativeways to reduce risk and reduce costs. From underwriting continuingeducation for insured physicians to providing discounts tohospitals that have implemented risk reduction measures,forward-thinking insurers know that small investments in safetytoday can reap significant future rewards.

Although any change in moving newly released over-the-counter (OTC)medications to benefit designs or formularies is currently beingdriven by health plans, other emerging market factors willinfluence how plans and employer groups think about coverage forOTCs. For example, Blue Cross and Blue Shield of Minnesota has hadnumerous inquiries about OTC coverage, usually from employer groupsthat know Medicaid and some Part D plans can cover OTCs. Inaddition, some states are evaluating their pharmacy practiceguidelines to determine how to revise them to accommodate changesin dispensing OTCs. This change is driven by the addition of OTCsto formularies and by the move to put pseudoephedrines behind thecounter. Another industry trend in some states, includingMinnesota, allows pharmacists to prescribe OTC products for publicprogram recipients.

Privatization of Medicare Part D has led to the emergence of manyplayers, both large and small. Navigating CMS regulations andsubsequent guidance has resulted in some administrative burdens, aswell as the inability to employ many managed care techniques, sayexperts.

Washington, D.C.-The Federal Trade Commission is concernedthat pharmaceutical companies increasingly are paying makers ofgeneric medications to delay marketing competitive products. FTCCommissioner Jon Leibowitz criticized "reverse payment"settlements, which involve compensation from a branded manufacturerlinked to restrictions on the marketing by a generic product'smanufacturer until closer to the expiration of an innovator'spatent.

Washington, D.C.-Insurers, pharmacists and Medicare officialshave established a formal partnership called the Pharmacy QualityAlliance (PQA) to improve measurement of pharmacy performance. Amajor function of the alliance will be to develop quality measures,new payment models and information systems to promote appropriatedrug treatment and to compensate pharmacists for supporting theseefforts.

More than 106 million American adults have borderline or high lipidlevels, which places them at increased risk for heart disease. Whenrecommended changes in diet and exercise do not sufficiently lowerhigh cholesterol levels, national medical guidelines call for theuse of lipid-lowering drugs.

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.

Specialty pharmacy s aware that value is becoming more important asa measure of a successful program.

Traditionally, pharmaceutical step therapy ensured the use of themost appropriate and clinically sound drug therapy for patientswith specific diseases or conditions. More recently however, steptherapy has been used as a cost containment tool by health plansand hospitals alike.

NATIONAL REPORTS-As part of its Critical Path initiative, FDAhas released a list of 76 high-priority research projects designedto modernize and advance medical product development. Thisprogram's goal is to bring medical innovations to patients quickerand at a lower cost.

All projections of rising healthcare costs assume that advances inmedical science will add to the cost. This is a reasonableassumption, since it has been uniformly true in the past.Antibiotics are a great advance, but bacteria develop resistanceand newer and more expensive antibiotics must be developed. Peoplewho would have died at home in the pre-antibiotic era now survive,but after the greater cost of antibiotics and, possibly,hospitalization. The same is true for advances in cardiac stents,cancer treatment, imaging with CT scanners and MRIs, etc. Thetechnology can be life-saving but is typically expensive.

Despite systemic challenges in caring for stroke patients, a care program developed by the American Stroke Assn. has shown promise in improving outcomes.

PITTSBURGH?Healthcare leaders need to be well-versed in leading change as healthcare delivery changes, according to industry experts.

About 60 million Americans a year experience insomnia often, or for extended periods of time, leading to problems in job performance and other activities. Insomnia affects about 40% of women and 30% of men.

Are pharmacy benefits managers (PBMs) that rely onrevenue-generating mail-order prescription service going to get arun for their money as 90-day retail programs hit the marketplace?Walgreen Health Initiatives (WHI), a PBM headquartered inDeerfield, Ill., is not particularly bothered by the new retailproduct. WHI launched Advantage90, a 90-day retail fulfillmentprogram, in late 2003 with more than 26,000 pharmacies nationwidenow participating in the program.

As the Centers for Medicare and Medicaid Services (CMS) tackles a host of start-up problems for the new Medicare prescription drug program, Administrator Mark McClellan, MD, is looking for ways to improve the system for next year. CMS has revised policies and updated information systems for Prescription Drug Plans (PDPs) and Medicare Advantage prescription drug plans (MA-PDs) in preparation for the 2007 contracting process, which begins in June.

The challenges of medical versus pharmacy benefits faced by payers are unique and vary by category, say industry watchers (See Desktop Resource, March 2006). Some of the following drug classes can fall under both benefit arrangements.

Savvy executives note challenges in pharmacy versus medical benefits, say industry experts.

In the United States today, 10 million people have osteoporosis (bone density that's about 25% less than a healthy young adult). In addition, 34 million more people have low levels of bone mass, placing them at increased risk. Osteoporosis is responsible for more than 1.5 million fractures annually, including 300,000 hip fractures, approximately 700,000 vertebral fractures, 250,000 wrist fractures, and more than 300,000 other fractures. About 68% of those affected by osteoporosis are women.

If misery loves company, then Beverly Thomas of Carbondale, Ill.,isn't alone. She is one of thousands of dual eligibles(beneficiaries covered by both Medicaid and Medicare) who went tothe pharmacy after January 1, 2006, only to find that it would notfill their prescriptions. Unfortunately, her medication for mentalillness is so critical that if she misses even a day, she could behospitalized. With the help of Southern Illinois Regional SocialServices, Thomas got squared away, but admits she still is confusedabout how the new Medicare Part D benefit operates.

WASHINGTON, D.C. -- Some pharmaceutical companies are dropping Patient Assistance Programs (PAPs) for seniors who enroll in the Medicare drug benefit program. They fear they'll be hit with fraud charges by the Office of the Inspector General (OIG) at HHS if they provide free or low-cost drugs to Medicare beneficiaries enrolled in prescription drug plans.

New molecular entities

Government, Employers, medical associations, payers, and many others are part of a nationwide momentum toward making electronic health records (EHRs) a reality. President Bush has cited the necessity to create EHRs, leading politicians of both parties have issued joint statements, and some states have accelerated activities. A number of initiatives by the Department of Health and Human Services (HHS), standards development organizations, and other groups are moving several issues ahead.

New molecular entities

When cultures enter Renaissance periods, new learning and ideas create transition. Heightened interest in the workings of pharmacy benefit management and subsequent changes in business philosophy represent a Renaissance for managed care. All key stakeholders will feel the ripples of change: payers, physicians, pharmacists, patients and pharmaceutical companies.

The Food and Drug Administration's (FDA) steps to advance the earliest phases of clinical research in the development of innovative medical treatments will have little short-term impact on managed care plans.

Medical registries have been used for many different purposes, including surveillance of rates of different diseases, rates of adverse events associated with medical interventions, rates of short-and long-term outcomes associated with medical interventions, quality improvement activities, post-marketing pharmaceutical intervention outcomes, diffusion of medical interventions and regional, racial and gender disparities.

The Medicare Payment Advisory Commission (Medpac) is conducting a survey to find out what factors have prompted Medicare beneficiaries to join or not join a Medicare drug plan. The aim is to learn more about what information and educational strategies are most useful in choosing a specific plan—including what may influence the selection of a stand-alone prescription drug plan (PDP) or a Medicare Advantage plan (MA-PD).

Total outlays for U.S. healthcare did not rise as fast as expected in 2004, primarily because private payers held the line on insurance premiums and outlays for prescription drugs. Overall spending on healthcare still increased by 7.9%—much faster than the rate of inflation—but below the 8% to 9% growth rates of the two previous years. Even with slower growth, though, U.S. healthcare expenditures amounted to almost $2 trillion, or more than $6,000 per person in 2004, and accounted for 16% of the nation's gross domestic product, about the same as the previous year.