Journal of managed care & specialty pharmacy最新文献

As a major provider of health insurance for working-age Americans, employers can play a significant role in improving the health equity of their employees and family members. In this commentary, we describe how different stakeholders, including employers, their employees, clinicians, and health systems and health plans, each contribute to the observed inequities. Other systems-level factors, including racism, implicit bias, medical mistrust, health literacy limitations, and health care access and affordability concerns have been also shown to contribute to inequitable outcomes. Opportunities exist for employers to improve health equity among their benefits-enrolled employees and family members using data-driven approaches to ensure that benefits are more equitable in scope, access, and affordability. As an illustrative example of employer strategic considerations, we describe opportunities to identify and address inequities in prescription medication use. Additionally, employers can, and perhaps should, advocate for transparency in community-based health system and health plan reporting regarding health inequities and progress toward more equitable health care utilization and outcomes. Employers can also advocate for the delivery of more patient-centered, systems-based solutions, such as enhanced primary care and/or worksite clinics, and give consideration to establishing health equity performance-based incentives in their health care contracting. Further research in the employer setting can help to expand the adoption of a best-practices approach to achieving more equitable health outcomes.

Background: Over the past 5 years, managed care pharmacy has been shaped by a global pandemic, advancements in generative artificial intelligence (AI), Medicare drug price negotiation policies, and significant therapeutic developments. Collective intelligence methods can be used to anticipate future developments in practice to help organizations plan and develop new strategies around those changes.

Objective: To identify emerging trends in managed care pharmacy.

Methods: In this sequential mixed-method study, we invited experts to participate in a multidisciplinary advisory panel to develop a survey with 5 overarching domains. The qualitative analysis for our advisory panel meetings used a thematic analysis approach. To analyze the cross-sectional survey results, we used descriptive statistics and exploratory bivariate statistics to test for possible relationships with survey respondent demographics and likelihood predictions. To assess respondent opinions on the overall likelihood of an event occurring in the next 5 years, we combined "Highly likely/Somewhat likely" responses and compared with "Highly unlikely/Somewhat unlikely" responses.

Results: Following our advisory panel focus groups, a total of 53 scenarios were developed for inclusion in the quantitative survey under the domains of (1) information technology, (2) therapeutics and diagnostics, (3) payment models, (4) pharmacy operations, and (5) public policy. A total of 1,238 individuals were invited to participate in the survey. Of eligible participants, 201 complete survey responses were received for a final response rate of 16.2%. Survey participants rated increased use of glucagon-like peptide-1 receptor agonists by at least 25%, at least 1 major data breach, more than 10 new orphan drug approvals, and AI use in more than half of prior authorization reviews as the most likely scenarios to occur in the next 5 years. Respondents identified the following broad issues as those most likely to impact their organizations (employers) in the next 5 years: federal and state policy changes impacting managed care, cell and gene therapies, impact of AI on managed care operations, and emerging payment models.

Conclusions: This study provides valuable insights into the emerging trends that are expected to shape managed care pharmacy over the next 5 years. The integration of advanced technologies, such as AI, along with the increasing focus on specialty therapeutics, represents both opportunities and challenges for managed care organizations. However, areas with lower consensus highlight the need for caution in strategic planning.

Background: Both glucagon-like peptide 1 receptor agonists (GLP-1 RAs) and continuous glucose monitoring (CGM) have been shown to improve glycated hemoglobin A1c (A1c) levels among patients with type 2 diabetes mellitus (T2DM). Recently, a US real-world study found statistically significant improvements in A1c levels among patients using GLP-1 RA and a CGM device, compared with a matched cohort receiving only GLP-1 RA.

Objectives: To assess the cost-effectiveness from a US payer perspective of initiating CGM (FreeStyle Libre Systems) in people living with T2DM using a GLP-1 RA therapy, compared with GLP-1 RA alone.

Methods: A patient-level microsimulation model was run for 10,000 patients over a lifetime horizon with 3.0% discounting for costs and utilities. Patient characteristics were based on the overall population of the US real-world study and the subgroup of patients not using intensive insulin. The effect of CGM was modeled as a persistent reduction in A1c compared with GLP-1 RA alone (overall = 0.37%; patients not using intensive insulin = 0.34%). Costs ($2,023) and disutilities were applied to diabetes complications and acute diabetic events. Outcomes were assessed as quality-adjusted life years (QALYs).

Results: The base-case incremental cost-effectiveness ratio (incremental costs/incremental QALYs) for GLP-1 RA plus CGM vs GLP-1 RA alone was $40,968/QALY in the overall cohort (cost = $484,180 vs $473,938; QALYs = 13.37 vs 13.12). Among patients not using intensive insulin, the incremental cost-effectiveness ratio was $43,095/QALY. Scenario analysis showed that the model results were robust to changing assumptions. Probabilistic sensitivity analysis showed that GLP-1 RA plus CGM had a 64% probability of being cost-effective at a willingness-to-pay threshold of $100,000 per QALY.

Conclusions: From a US payer perspective, CGM is cost-effective when added to GLP-1 RA therapies for the treatment of T2DM, including for patients not using intensive insulin.

Background: Type 2 diabetes (T2D) causes increased health care resource utilization (HCRU) and costs in the United States. People with T2D are more likely to have atherosclerotic cardiovascular disease (ASCVD), which is associated with significant morbidity and mortality. Medical associations recommend cardioprotective antidiabetic medications, including sodium-glucose cotransporter-2 inhibitors (SGLT2is) and glucagon-like peptide 1 receptor agonists (GLP-1 RAs), to reduce the risk of cardiovascular events in patients with T2D with established, or a high risk of, ASCVD, but not all eligible patients receive these medications.

Objective: To describe demographic/clinical characteristics and antidiabetic medication prescription patterns and compare HCRU and costs among patients with T2D and ASCVD with or without SGLT2i and/or GLP-1 RA use.

Methods: We conducted a retrospective cohort study using the Merative MarketScan database of longitudinal US health care claims data with patients enrolled from July 1, 2014, to December 31, 2022. Patients with T2D and ASCVD receiving SGLT2is and/or GLP-1 RAs (case cohort) were compared with patients with T2D and ASCVD not receiving SGLT2is and/or GLP-1 RAs (control cohort) during a 12-month baseline period pre-index and a 12-month follow-up period post-index. The index date was SGLT2i/GLP-1 RA prescription for the case cohort and random health care visit for the control cohort. Baseline patient characteristics are reported before propensity score matching (PSM); HCRU and medical costs are reported after PSM.

Results: Before PSM, each cohort included 3,386 patients; after PSM, each cohort included 2,351 patients. Patients in the case cohort were significantly more likely to experience myocardial infarction (case, 26.2%; control, 21.5%; P < 0.001) or peripheral artery disease (case, 28.6%; control, 26.1%; P < 0.024) during the baseline period. Patients in the case cohort had significantly lower baseline Charlson Comorbidity Index scores than patients in the control cohort (case, 1.8; control, 2.1; P < 0.001). Patients in the case cohort had significantly fewer all-cause inpatient visits per patient (case, 0.4; control, 0.6; P < 0.001) and all-cause emergency department visits per patient (case, 0.9; control, 1.0; P = 0.024). Patients in the case cohort had significantly lower all-cause inpatient costs (case, $13,977; control, $22,056; P < 0.001), other all-cause outpatient costs (case, $16,504; control, $24,739; P < 0.001), and all-cause total medical costs including pharmacy costs (case, $51,143; control, $58,648; P = 0.01) in the 12-month follow-up period.

Conclusions: Patients with T2D and ASCVD receiving SGLT2is and/or GLP-1 RAs within 12 months of ASCVD diagnosis may benefit from lower HCRU and costs.