American journal of hospital pharmacy
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The fundamental components of managed-care plans are described; the development of managed-care programs is discussed; and the impact of managed care on pharmacy services and the price, quality, and accessibility of health care are reviewed. Health care can be considered to be managed when at least one of the following fundamental components is present: prospective pricing, "UCR" (usual, customary, and reasonable) pricing of services, peer review, mandatory use review, benefit redesign, capitation payments, channeling, quality criteria, and health promotion. The managed-care industry consists of health maintenance organizations (HMOs), preferred provider organizations (PPOs), and managed fee-for-service plans. ⋯ However, since shorter hospital stays are not associated with a linear decline in the need for drug therapy, reducing pharmacy operating expenses in proportion to the decline in hospital occupancy is probably not possible. Community pharmacies have responded to managed care by forming pharmacy services administrative organizations. Application of managed-care principles has reduced the use of inpatient hospital services by Medicare beneficiaries, helped HMOs and PPOs to lower prices for some services, reduced use of hospital services by HMO members, and redirected some inpatient hospital care to alternate-care providers.(ABSTRACT TRUNCATED AT 400 WORDS)