|Implemented in this survey?|
Efforts to use research evidence about drugs? effectiveness, safety, cost, etc. to drive decisions about coverage and purchasing, as well as, increase access to more effective drugs, and improve quality. These changes are implemented through preferred drug lists (PDLs), disease management, provider informing, and changes to claims processing system.
In the United States, spending for prescription drugs grew from a little over $40 billion in 1990 to over $140 billion in 2001, an increase of about 250%. During 2001 alone, Medicaid spent a total of $24.2 billion on prescription drugs, approximately 11% of total Medicaid spending. States are especially hard hit by rising drug costs. (See Background Note on Medicaid Program below)
Although prescription drugs are costly, states recognize that advances in pharmaceutical therapies save lives, improve health status and quality of life, and potentially contain costs for other
types of health services. The proper use of drugs for certain conditions has been shown to reduce the likelihood of complications requiring hospitalization or other expensive treatments.
These facts present a challenge to states that are trying to contain pharmaceutical costs and facilitate appropriate access. As a result, states are implementing different strategies to contain pharmaceutical costs and promote appropriate access. Examples of the strategies that states have implemented include the following.
Among these three approaches implementing a PDL is the most likely to be used by state Medicaid agencies-and much of the rest of this report focuses on that approach.
Different financial and non-financial incentives exist (or can be created) for the various stakeholders (patients, physicians, pharmacists, manufacturers, and payors) involved in implementing these policies. Essentially, however, these incentives can be reduced to three that effect each to some extent..
Background on the Medicaid Program- from Policy Brief #3): Title XIX of the Social Security Act is a program which provides medical assistance for certain
individuals and families with low incomes and resources. The program, known as Medicaid, became law in 1965 as a jointly funded cooperative venture between the Federal and State governments to assist
States in the provision of adequate medical care to eligible low-income and needy persons. Medicaid is the largest program providing medical and health-related services to America's
poorest people. The program has essentially been a State/Federal funds match in which state dollars spent for Medicaid beneficiaries are matched by the Federal government Within broad national
guidelines which the Federal government provides, each of the States: 1. establishes its own eligibility standards (the neediest populations are required); 2. determines the type, amount, duration,
and scope of services; 3. sets the rate of payment for services; and 4. administers its own program.
Thus, the Medicaid program varies considerably from State to State, as well as within each State over time. For example, outside of the neediest population which is required to be covered, a person who is eligible for Medicaid in one State may not be eligible in another State, and the services provided by one State may differ considerably in amount, duration, or scope from services provided in a similar or neighbouring State. In addition, State legislatures may change Medicaid eligibility and/or services during the year.
A State's Medicaid program must offer medical assistance for certain basic services to most categorically needy populations. States may also receive Federal matching funds to provide certain optional services.
 Office of the Actuary, National Health Expenditure Projections 2002-2012, (Centers for Medicare & Medicaid Services, February 2003). http://www.cms.hhs.gov/statistics/nhe/
 Jack Hoadley, How States Are Responding to the Challenge of Financing Health Care for Retirees (Henry J. Kaiser Family Foundation, September 2003).
 Jeffrey S. Crowley, Deb Ashner, and Linda Elam, Medicaid Outpatient Prescription Drug Benefits: Findings from a National Survey, 2003, Kaiser Commission on Medicaid and the Uninsured, December 2003.
The main objective of these efforts is to better manage the pharmacy benefit (in terms of cost, access, and quality) through the application of research evidence to coverage and purchasing decisions.
There are both financial and non-financial incentives offered to various stakeholders. For example,
Medicaid beneficiaries, state employees and other groups of people for which states purchase health care., Physicians, pharmacists, and other health care providers, Pharmaceutical manufacturers, 4. State purchasers of health care (Medicaid agencies, SCHIP programs, State employee and retiree benefits purchasing agencies, etc.)
|Medienpräsenz||sehr gering||sehr hoch|
These changes were not driven by a change in government or political direction. Instead rising health care costs, state budget shortfalls, and a continuing need for states to provide those
they cover (Medicaid beneficiaries, state employees, etc) with access to quality health care drove these changes. These factors created the need for states to develop means for better
management of the pharmacy benefit (access, cost, and quality) within the current national and state regulatory structure.
Medicaid regulations make the use of a closed formulary very difficult, but prior authorization programs are expressly permitted-and used by states to manage many other services. Also, a pharmacy rebate program was created as part of the Omnibus Budget Reconciliation Act (OBRA) of 1990-all states already have systems and processes in place for collecting these rebates. These factors made using the combination of prior authorization, and manufacturer rebates extremely attractive to states. The introduction of research evidence into these purchasing decisions helps states ensure that these decisions do not compromise patient care-and help overcome the resistance of providers, participants, and advocates to these changes.
Nonetheless, pharmaceutical manufacturers challenged state use of these procedures-impelling CMS to issue a letter to state Medicaid Directors supporting the use of prior authorization, rebates, and research evidence to manage the pharmacy benefit (SMDL #02-014, issued September 2002; www.cms.hhs.gov/states/letters/smd91802.pdf).
Manufacturers also challenged these processes by taking some of the pioneering states, such as Michigan, to court and on March 28, 2003 the U.S. District Court for the District of Columbia ruled that Michigan's preferred drug list, prior authorization and supplemental rebate policies were acceptable under federal law.
|Implemented in this survey?|
Please see earlier description on the genesis of this approach. In summary, however:
The use of evidenced to better manage pharmacy services has had strong supporters and opponents. In general:
Over time, most stakeholders have come to accept or support the approach.
Many policy papers have been formulated-mostly by individual states or organisations including, universities, provider and consumer advocacy organisations, etc.
In most cases the policy required state legislation before implementation and was, in some cases, changed during the legislative process. For example, legislation establishing a PDL may have been changed to exclude psychotropic drugs or limit the use of prior authorization to reinforce the requirements.
The participation of all of the stakeholders identified above is needed for successful implementation of the policy. State experience has shown that even those who strongly object to the
policy are likely to participate. For example, pharmaceutical manufacturers are generally opposed to any strategies that might create a barrier to a patient's use of their drug-but the
manufacturers nonetheless do usually decide to participate in the effort.
The process of adopting/implementing the policy is spearheaded usually by a state agency that purchases prescription drugs. They can be considered the 'moderator' of the process. The tools needed to successfully implement this policy include:
Although most states have not established a formal review process the state budget process will bring these policies (PDLs) under public scrutiny on an annual basis. They are, of course,
also evaluated on an ongoing basis by the state purchasing agency to ensure that they are producing sufficient changes in utilization and cost.
Since each state acts independently these evaluations can be conducted internally, or contracted out. But, most examine changes in pharmacy cost and utilization as measures of the success of the policy. State purchasers wish to see reductions in cost and shifts toward using those drugs that are included on the list. They believe that these changes in utilization will produce better patient outcomes, but it is difficult to identify whether changes outside pharmacy are related to the changes in pharmacy services because there are so many other factors that also impact services and outcomes.
This policy is expected to improve access and quality while containing costs. It appears, based on state report, to be achieving those objectives. However, the policy does create a clear barrier to obtaining some prescription drugs-it is possible that some would benefit from the 'non-preferred' drugs and they will have difficulty obtaining them.
|Qualität||kaum Einfluss||starker Einfluss|
|Gerechtigkeit||System weniger gerecht||System gerechter|
|Kosteneffizienz||sehr gering||sehr hoch|
States that use this approach report that they see changes in cost and utilization that indicate that the policy influences prescribing. The extent of the impact does vary among states. Given that these policies are based on scientific evidence about relative safety, effectiveness etc. of specific drugs these changes should improve the quality of care-they clearly reduce pharmacy costs. It is difficult, however, to determine the impact of these changes impact on services other than pharmacy (such as hospitalization) because there are many other factors that could influence changes in other service areas.
Neva Kaye. Affording Prescription Drugs: State Initiatives to Contain Cost and Improve Access.(National Academy for State Health Policy, July 2002). www.nashp.org/_docdisp_page.cfm?LID=666CB5DC-7948-11D6-BD1700A0CC76FF4C
Jack Hoadley. How States Are Responding to the Challenge of Financing Health Care for Retirees. (Henry J. Kaiser Family Foundation, September 2003).
Jeffrey S. Crowley, Deb Ashner, and Linda Elam. Medicaid Outpatient Prescription Drug Benefits: Findings from a National Survey, 2003. (Henry J. Kaiser Family Foundation, December 2003). www.kff.org/medicaid/4164.cfm
Cathy Bernasek, et al. Oregon's Medicaid PDL: Will an Evidence-Based Formulary with Voluntary Compliance Set a Precedent for Medicaid? (Henry J. Kaiser Family Foundation, December 2003). www.kff.org/medicaid/4173.cfm
Peter Neumann, "Evidence-Based and Value-Based Formulary Guidelines," Health Affairs 23(1) January/February 2004, pp. 124-134.
Center for Evidence-Based Policy. Drug Effectiveness Review Project. (website) www.ohsu.edu/drugeffectiveness/description/index.htm
Neva Kaye, National Academy for State Health Policy