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All of these practices, and more, aim to ensure that all patients can receive the medications they need to improve their health and wellbeing. Managed care pharmacy professionals who are members of the Academy of Managed Care Pharmacy (AMCP) uphold the vision of our organization, which is to “improve health care for all.”
Tied to Healthcare Reform How are decisions about the value of medications made? This task falls primarily to a health plan’s pharmacy and therapeutics committee (P&T committee). Made up of pharmacists, physicians and other healthcare professionals, P&T committees strive to determine the value of new medications by examining all available scientific data on the product. Only then do they make a recommendation as to how the health plan should position the product relative to similar therapies. The practices of the P&T committee have much in common with the 2010 Affordable Care Act, which emphasizes finding and establishing value in healthcare delivery. Managed care pharmacy is well positioned to play a major role under the new law. By 2016, an estimated 30 million individuals are expected to obtain health insurance from private health plans participating in state insurance exchanges, as well as through state expansion of Medicaid programs. These plans must contain a federally determined “essential health benefits package”—a package that requires access to prescription medications.
While managed care pharmacy applauds this provision, AMCP has asked the Department of Health and Human Services to include not only access to medications, but the management of medication therapies as well. In addition, AMCP has proposed to HHS that health plans maintain autonomy over the design of the drug benefit, as well as the determination of which medications are to be covered and deemed essential. Flexibility in making medication coverage decisions, and in designing the overall pharmacy benefit, will allow managed care organizations to incorporate a range of best practices to improve clinical outcomes and control costs.
Keeping Costs Low Managed care pharmacy professionals take seriously the need to carefully manage limited resources. And in today’s world that means they must be cognizant of costs. Some believe that managed care pharmacy focuses too much on costs, and that costs are controlled by putting up hurdles to access and burdensome restrictions on certain medications. The response to that argument is the underlying principle in managed care pharmacy: that medications are examined based on their value, not simply their sticker price. This means evaluating their overall effectiveness in improving health outcomes. In other words, it may make sense to spend extra on a particular medicine today if it will keep a patient away from a more costly hospital stay tomorrow.
academic Pharmacy now Fall 2012
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