Pub Date : 2015-09-15DOI: 10.18553/JMCP.2001.7.3.233
C. McCall
OBJECTIVES: After completing this continuing education program, readers will be able to: 1. understand the general problems actuaries face in pricing health insurance, 2. explain how insurance is priced differently from other products, 3. describe the role of an actuary in pricing health insurance, and 4. discuss the contributions pharmacists can make to that work.
{"title":"Rear Window: Actuaries and Pharmacists Toward a New Competency","authors":"C. McCall","doi":"10.18553/JMCP.2001.7.3.233","DOIUrl":"https://doi.org/10.18553/JMCP.2001.7.3.233","url":null,"abstract":"OBJECTIVES: After completing this continuing education program, readers will be able to: 1. understand the general problems actuaries face in pricing health insurance, 2. explain how insurance is priced differently from other products, 3. describe the role of an actuary in pricing health insurance, and 4. discuss the contributions pharmacists can make to that work.","PeriodicalId":50156,"journal":{"name":"Journal of Managed Care Pharmacy","volume":"1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2015-09-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67489981","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2015-09-15DOI: 10.18553/JMCP.2001.7.4.268
C. Perry
{"title":"Employee Benefits Consulting: An Essential Role for Pharmacy","authors":"C. Perry","doi":"10.18553/JMCP.2001.7.4.268","DOIUrl":"https://doi.org/10.18553/JMCP.2001.7.4.268","url":null,"abstract":"","PeriodicalId":50156,"journal":{"name":"Journal of Managed Care Pharmacy","volume":"1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2015-09-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67490045","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2015-09-15DOI: 10.18553/JMCP.2001.7.6.490
Michael Smith
{"title":"Managed Care and The University of Texas College of Pharmacy","authors":"Michael Smith","doi":"10.18553/JMCP.2001.7.6.490","DOIUrl":"https://doi.org/10.18553/JMCP.2001.7.6.490","url":null,"abstract":"","PeriodicalId":50156,"journal":{"name":"Journal of Managed Care Pharmacy","volume":"1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2015-09-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67490077","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2015-09-15DOI: 10.18553/JMCP.2001.7.5.407
D. Fick, J. Waller, J. R. Maclean, Richard Vanden Heuvel, M. Gottlieb, C. Cangialose
RESULTS: The prevalence of PIM use in this Medicare managed care population was 24.2% (541/2,336). Eightyeight of the 146 individuals on two or more inappropriate medications had 4‐13 providers prescribing all their medications. Those on a PIM had significantly higher total, provider, and facility costs, and a higher mean number of inpatient, outpatient, and emergency room visits than comparisons after controlling for sex, Charlson comorbidity index, and total number of prescriptions. CONCLUSIONS: Our study revealed a high prevalence of potentially inappropriate medication use among older adults in a managed care plan and an association with high resource utilization. In this study, we sought to gather evidence to guide the future development of an intervention and educational program to decrease the use of high-risk medications in older adults.
{"title":"Potentially Inappropriate Medication Use in a Medicare Managed Care Population: Association with Higher Costs and Utilization","authors":"D. Fick, J. Waller, J. R. Maclean, Richard Vanden Heuvel, M. Gottlieb, C. Cangialose","doi":"10.18553/JMCP.2001.7.5.407","DOIUrl":"https://doi.org/10.18553/JMCP.2001.7.5.407","url":null,"abstract":"RESULTS: The prevalence of PIM use in this Medicare managed care population was 24.2% (541/2,336). Eightyeight of the 146 individuals on two or more inappropriate medications had 4‐13 providers prescribing all their medications. Those on a PIM had significantly higher total, provider, and facility costs, and a higher mean number of inpatient, outpatient, and emergency room visits than comparisons after controlling for sex, Charlson comorbidity index, and total number of prescriptions. CONCLUSIONS: Our study revealed a high prevalence of potentially inappropriate medication use among older adults in a managed care plan and an association with high resource utilization. In this study, we sought to gather evidence to guide the future development of an intervention and educational program to decrease the use of high-risk medications in older adults.","PeriodicalId":50156,"journal":{"name":"Journal of Managed Care Pharmacy","volume":"1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2015-09-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.18553/JMCP.2001.7.5.407","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67490255","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2015-09-15DOI: 10.18553/JMCP.2001.7.6.468
Eric J. Culley, Robert Wanovich
were analyzed during the same time periods. RESULTS: The quantity limit resulted in an overall drug and medical cost savings of $420,754 during the six months after initiation of the program. The utilization and costs associated with the triptans and other analgesic medications decreased, while the percentage of patients taking prophylactic therapy increased. A small change in utilization and costs of hospitalizations, PCP visits, ER visits, and neurologist visits was noted.
{"title":"Medical and Pharmacy Cost and Utilization Outcomes of a Quantity Limit on the 5-HT1 Agonists (Triptans) by a Managed Care Organization","authors":"Eric J. Culley, Robert Wanovich","doi":"10.18553/JMCP.2001.7.6.468","DOIUrl":"https://doi.org/10.18553/JMCP.2001.7.6.468","url":null,"abstract":"were analyzed during the same time periods. RESULTS: The quantity limit resulted in an overall drug and medical cost savings of $420,754 during the six months after initiation of the program. The utilization and costs associated with the triptans and other analgesic medications decreased, while the percentage of patients taking prophylactic therapy increased. A small change in utilization and costs of hospitalizations, PCP visits, ER visits, and neurologist visits was noted.","PeriodicalId":50156,"journal":{"name":"Journal of Managed Care Pharmacy","volume":"1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2015-09-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67490372","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2015-09-15DOI: 10.18553/JMCP.2007.13.S2-B.1
S. Cornell, J. Dunn, M. O’Kane, Allen L. Smith
BACKGROUND: Pay for performance (P4P) initiatives are designed to foster and reward improvement in health care delivery. These programs promote “value-based health care” by rewarding quality care that is characterized by a reduced amount of disproportionate spending. OBJECTIVE: To review the intent and design of P4P initiatives as well as the design and results of P4P programs in current practice. SUMMARY: Three key principles are fundamental to building a value-based health care system: measurement, transparency, and accountability. There are several levers currently driving P4P, each influencing the movement in its own way. Among these are employers, federal agencies such as the Centers for Medicare & Medicaid Services and the Department of Health and Human Services, health plans, providers, accreditors, and Congress. One key player in the P4P movement, the National Committee for Quality Assurance (NCQA), is a private, independent nonprofit health care quality oversight organization that measures and reports on health care quality and unites diverse groups around a common goal: improving health care quality. NCQA, has demonstrated several successful provider-level measurement initiatives connected to P4P programs, notable among them Bridges to Excellence programs in several markets, physician recognition programs, the Integrated Healthcare Association’s P4P initiative in California, the National Forum on Performance Benchmarking of Physician Offices and Organizations, and health plan accreditation. CONCLUSIONS: The initial data from developmental P4P programs across the nation have indicated that both financial and nonfinancial incentives motivate significant change in health care delivery, but the return on investment of these initiatives is not yet known.
{"title":"Pay for Performance: Where's The Return?","authors":"S. Cornell, J. Dunn, M. O’Kane, Allen L. Smith","doi":"10.18553/JMCP.2007.13.S2-B.1","DOIUrl":"https://doi.org/10.18553/JMCP.2007.13.S2-B.1","url":null,"abstract":"BACKGROUND: Pay for performance (P4P) initiatives are designed to foster and reward improvement in health care delivery. These programs promote “value-based health care” by rewarding quality care that is characterized by a reduced amount of disproportionate spending. OBJECTIVE: To review the intent and design of P4P initiatives as well as the design and results of P4P programs in current practice. SUMMARY: Three key principles are fundamental to building a value-based health care system: measurement, transparency, and accountability. There are several levers currently driving P4P, each influencing the movement in its own way. Among these are employers, federal agencies such as the Centers for Medicare & Medicaid Services and the Department of Health and Human Services, health plans, providers, accreditors, and Congress. One key player in the P4P movement, the National Committee for Quality Assurance (NCQA), is a private, independent nonprofit health care quality oversight organization that measures and reports on health care quality and unites diverse groups around a common goal: improving health care quality. NCQA, has demonstrated several successful provider-level measurement initiatives connected to P4P programs, notable among them Bridges to Excellence programs in several markets, physician recognition programs, the Integrated Healthcare Association’s P4P initiative in California, the National Forum on Performance Benchmarking of Physician Offices and Organizations, and health plan accreditation. CONCLUSIONS: The initial data from developmental P4P programs across the nation have indicated that both financial and nonfinancial incentives motivate significant change in health care delivery, but the return on investment of these initiatives is not yet known.","PeriodicalId":50156,"journal":{"name":"Journal of Managed Care Pharmacy","volume":"1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2015-09-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"67492509","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2015-09-15DOI: 10.18553/jmcp.1997.3.1.22
C. Sardinha
{"title":"Managed Care Formularies: An Effective Tool?","authors":"C. Sardinha","doi":"10.18553/jmcp.1997.3.1.22","DOIUrl":"https://doi.org/10.18553/jmcp.1997.3.1.22","url":null,"abstract":"","PeriodicalId":50156,"journal":{"name":"Journal of Managed Care Pharmacy","volume":"1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2015-09-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"68349741","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2015-09-15DOI: 10.18553/JMCP.1997.3.1.46
D. Scott
OBJECTIVE: To assess the willingness of insurance carriers to reimburse for pharmaceutical care and to determine the extent and success of the Pharmacist Care Claim Form (PCCF) used in obtaining reimbursement. DESIGN: A nine-item survey addressing the PCCF (compiled by the National Community Pharmacists Association, formerly the National Association of Retail druggists. Reimbursement was sent to a random sample of insurance carriers including Blue Cross/Blue Shield, health maintenance organizations (HMOs), preferred provider organizations (PPOs), and commercial insurance companies. RESULT: Overall, 116 of 311 (37.3%) surveys were returned (Blue Cross, 57.4%; HMOs, 41.6%; PPOs, 30.7%; and commercial carriers, 27.0%). Of insurance carriers, 6.9% of 116 respondents reported they had reimbursed pharmacists for nondispensing activities. Two carriers reported reimbursement for "monitoring of drug therapy" and "prescription counseling." Only two health insurance carriers reported reimbursement to pharmacists usi...
{"title":"Reimbursement for Pharmacy Cognitive Services: Insurance Company Assessment","authors":"D. Scott","doi":"10.18553/JMCP.1997.3.1.46","DOIUrl":"https://doi.org/10.18553/JMCP.1997.3.1.46","url":null,"abstract":"OBJECTIVE: To assess the willingness of insurance carriers to reimburse for pharmaceutical care and to determine the extent and success of the Pharmacist Care Claim Form (PCCF) used in obtaining reimbursement. DESIGN: A nine-item survey addressing the PCCF (compiled by the National Community Pharmacists Association, formerly the National Association of Retail druggists. Reimbursement was sent to a random sample of insurance carriers including Blue Cross/Blue Shield, health maintenance organizations (HMOs), preferred provider organizations (PPOs), and commercial insurance companies. RESULT: Overall, 116 of 311 (37.3%) surveys were returned (Blue Cross, 57.4%; HMOs, 41.6%; PPOs, 30.7%; and commercial carriers, 27.0%). Of insurance carriers, 6.9% of 116 respondents reported they had reimbursed pharmacists for nondispensing activities. Two carriers reported reimbursement for \"monitoring of drug therapy\" and \"prescription counseling.\" Only two health insurance carriers reported reimbursement to pharmacists usi...","PeriodicalId":50156,"journal":{"name":"Journal of Managed Care Pharmacy","volume":"1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2015-09-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"68349888","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2015-09-15DOI: 10.18553/jmcp.1997.3.1.55
G. Gilomen-Stūdy
OBJECTIVE: To identify perspectives of primary care physicians in a staff-model health maintenance organization (HMO) concerning a therapeutic conversion program conducted for the drug class HMG-CoA reductase inhibitors. DESIGN: Multi-site, observational study. SETTING: 11 ambulatory care medical practices within a staff-model HMO serving 100,000 patients in the midwestern United States. PARTICIPANTS: 25 adult medicine physicians specializing in internal medicine or family practice. MAIN OUTCOME MEASURES: Physicians' perspectives of 13 components of the Lescol (fluvastatin) therapeutic conversion program as measured by a Likerttype scale. RESULTS: Means were used to quantify the overall response for each item. Findings indicated that the program rationale was clear, the supporting communications were useful, the inconveniences were slight, the patient feedback was neutral, and, on average, any clinical concerns about Lescol were insignificant. CONCLUSION: The responding physicians were not displeased with...
{"title":"Physicians' Perspectives of a Therapeutic Conversion within a Staff-model HMO","authors":"G. Gilomen-Stūdy","doi":"10.18553/jmcp.1997.3.1.55","DOIUrl":"https://doi.org/10.18553/jmcp.1997.3.1.55","url":null,"abstract":"OBJECTIVE: To identify perspectives of primary care physicians in a staff-model health maintenance organization (HMO) concerning a therapeutic conversion program conducted for the drug class HMG-CoA reductase inhibitors. DESIGN: Multi-site, observational study. SETTING: 11 ambulatory care medical practices within a staff-model HMO serving 100,000 patients in the midwestern United States. PARTICIPANTS: 25 adult medicine physicians specializing in internal medicine or family practice. MAIN OUTCOME MEASURES: Physicians' perspectives of 13 components of the Lescol (fluvastatin) therapeutic conversion program as measured by a Likerttype scale. RESULTS: Means were used to quantify the overall response for each item. Findings indicated that the program rationale was clear, the supporting communications were useful, the inconveniences were slight, the patient feedback was neutral, and, on average, any clinical concerns about Lescol were insignificant. CONCLUSION: The responding physicians were not displeased with...","PeriodicalId":50156,"journal":{"name":"Journal of Managed Care Pharmacy","volume":"1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2015-09-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.18553/jmcp.1997.3.1.55","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"68349964","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2015-09-15DOI: 10.18553/JMCP.1997.3.2.200
E. Armstrong
{"title":"Pharmacoeconomic Analysis of Hormone Replacement Therapy-Implications for Managed Care","authors":"E. Armstrong","doi":"10.18553/JMCP.1997.3.2.200","DOIUrl":"https://doi.org/10.18553/JMCP.1997.3.2.200","url":null,"abstract":"","PeriodicalId":50156,"journal":{"name":"Journal of Managed Care Pharmacy","volume":"1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2015-09-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"68350256","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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