Journal of managed care pharmacy : JMCP
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Cardiovascular disease (CVD) is considered to be the main cause of death and one of the most common diseases affecting health care systems worldwide. Many methods have been used to improve CVD outcomes, one of which is to involve clinical pharmacists in the direct care of patients with CVD. ⋯ The involvement of a pharmacist demonstrated an ability to improve CVD outcomes through providing educational intervention, medicine management intervention, or a combination of both. These interventions resulted in improved CVD risk factors, improved patient outcomes, and reduced number of drug-related problems with a direct effect on CVD control. These improvements may lead to an improvement in patient quality of life, better use of health care resources, and a reduced rate of mortality.
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Health plans and pharmacy benefit managers have implemented utilization management strategies for newer type 2 diabetes mellitus (T2DM) medications to control pharmacy expenditures. Little is known about the impact of utilization management strategies on overall health care costs and subsequent use of T2DM medications among members who request, but do not receive, a T2DM medication requiring prior authorization (PA). ⋯ This study found higher plan-paid health care costs (overall and medical alone) among members who requested a type 2 diabetes medication requiring PA, but never received it, compared with those who qualified for and received the requested medication. A notable number of individuals who were assumed to have met the criteria based on a claims-based equivalent, but who never received the medication, made no change to their current therapy. Failure of a member to take medication deemed necessary by his or her physician could translate to inadequate control of the diabetic condition and result in an excess of resource utilization and costs for treating the disease and associated comorbidities. In light of the present findings, health plans should consider not only the impact of utilization management strategies on reducing pharmacy costs, but the broader implication for overall health care costs and subsequent treatment patterns among members.
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Comparative Study
Quality compensation programs: are they worth all the hype? A comparison of outcomes within a Medicare advantage heart failure population.
Quality compensation programs (QCPs), also known as pay-for-performance programs, are becoming more common within managed care entities. QCPs are believed to yield better patient outcomes, yet the programs lack the evidence needed to support these claims. We evaluated a QCP offered to network primary care physicians (PCPs) within a Medicare managed care plan to determine if a positive correlation between outcomes and the program exists. ⋯ After evaluation of our QCP's impact on the quality of care provided to our Medicare beneficiaries, we have concluded that there is potential for health care improvement through pay-for-performance programs. We have observed in our MAPD heart failure population, enrolled in a QCP during the year of 2010, an increase in age and CMS risk scores, a decline in renal function, and noted the group to have a more female presence. Yet, the outcomes of this group (hospitalizations, ER visits, acquisition of lab tests, etc.) were similar when compared with younger, healthier members not enrolled in a QCP. We feel the clinical relevance of the data indicates that, overall, the quality of care is somewhat improved for QCP-enrolled providers when compared with non-QCP providers in regards to achieving certain quality metrics. (i.e., immunizations, HgA1c, LDL-C, etc.) Further research is definitely needed to determine if health care costs and clinical outcomes, in the long term, are improved for members enrolled in these QCP programs, as well as their impact upon a health plan's Medicare Star rating.
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Atrial fibrillation (AF) imposes a substantial clinical and economic burden on the U.S. health care system. Despite national guidelines that recommend oral anticoagulation for stroke prevention, the literature consistently reports its underuse in AF patients with moderate to high stroke risk. ⋯ Our results confirm that underutilization and nonadherence of warfarin among nonvalvular AF patients is both prevalent and costly. Warfarin use among patients with moderate to high stroke risk and low to moderate bleed risk demonstrated a stroke benefit without a significant increase in intracranial hemorrhage. Adherence to oral anticoagulant therapy was associated with a significant reduction in inpatient service use and total health care cost. Improving adherence to oral anticoagulation is important to attaining the clinical and economic benefits of therapy.
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Warfarin is the predominant oral anticoagulant used for the prevention of recurrent venous thromboembolism (VTE) events. However, its long-term use is complicated by the need to manage the drug within a narrow therapeutic range and by possible food and drug interactions. ⋯ Adherence to a year of therapy was low in patients at high risk of recurrent VTE, even though long-term therapy should be considered in this population. Noncompliance and discontinuation of warfarin treatment over a 1-year period was associated with a higher risk of recurrent VTE. Future research should investigate and differentiate between patient and provider discontinuation to develop strategies to improve compliance and persistence with appropriate anticoagulation therapy that may potentially reduce recurrent VTE.