FDA expedited approval and implications for rational formulary and health plan design.

DISCLOSURES: No funding supported this commentary. The authors are employed by Humana, Inc. Shrank reports board of directors work for GetWell Network and NCQA. The other authors have nothing to disclose.

Pharmacy management strategies for improving drug adherence.

BACKGROUND: Significant gaps in quality pervade U.S. health care, leading to suboptimal care and rising costs. One key factor driving the apparent quality gaps and rising costs in the current health care system is the issue of nonadherence to prescription medications. OBJECTIVE: To describe quality gaps in managed care that are driven by nonadherence to prescription medications and characterize the components of successful pharmacy management strategies for overcoming nonadherence. SUMMARY: Collaborative networks and medication therapy management (MTM) programs are 2 pharmacy management initiatives that are useful in reducing medication nonadherence among plan members. The Pharmacy Quality Alliance has laid the foundation for developing useful pharmacy quality metrics, aggregating data, and reporting to both consumers and pharmacies. At the same time, the National Committee for Quality Assurance has developed MTM measures to monitor pharmacy quality. Both organizations have used Medicare Part D as an impetus for these initiatives in an effort to assess the value of the high-cost investment in prescription drugs resulting from the government mandate. CONCLUSION: Managed care stakeholders should strive toward a valuebased health care system by investing more on appropriate medication use, including initiatives to reduce nonadherence and avoid the high costs of treating severe disease in the future.

AHRQ's Effective Health Care Program: its impact on managed care.

OBJECTIVE: To describe some of the managed care perspectives regarding the data development and coverage issues. BACKGROUND: Section 1013 of the Medicare Modernization Act of 2003 has initiated the formation of the Agency for Healthcare Research and Quality (AHRQ) Effective Health Care Program, which is evaluating the treatments for rheumatoid arthritis (RA) in the Medicare population. The results of these studies have the potential to impact future drug utilization. It is not known whether this data could be applied to the commercial population. SUMMARY: Payers (e.g., managed care organizations, pharmacy benefit managers) make decisions about which drugs will be covered and to which formulary "tier" the drug will be assigned. These decisions are made by evaluating current evidence based on safety, effectiveness, outcomes, and cost. Patients believe in a "warranty" of care, meaning that there will always be a treatment option whether they are compliant with their treatment regimen or not. All treatments are measured by a "value," and each stakeholder may see this value differently. A return on medical investment is one way to assess this value. CONCLUSIONS: Different stakeholders view treatment value in different ways. The evidence that will be identified through AHRQ's Effective Health Care Program will partially define this value. If this model succeeds, it has the potential to significantly affect health care.