Managing drug costs: the perception of managed care pharmacy directors.

OBJECTIVE: To examine the perceptions of health plan pharmacy directors about drug costs and utilization drivers, interventions the plans use to control drug expenditures, and strategies considered necessary to permit continued provision of a comprehensive drug benefit. STUDY DESIGN/METHODS: A multipart survey developed and mailed to 500 pharmacy directors of managed care organizations across the country. RESULTS: The survey respondents (response rate = 18%) represented managed care health plans in the following percentages: 49% of respondents were from network/independent practice associations; mixed-model health maintenance organizations (HMOs), 20%; group HMOs, 15%; and staff-model HMOs and network/preferred provider organizations, 8% each. Drug mix and utilization were reported to be the primary drivers of drug expenditures. Half the respondents rated inflation as a somewhat strong cost driver. Interventions the health plans use to control drug expenditures include formularies, generic substitution, preauthorization, manufacturers' rebates, drug benefit design, physician profiling, target drug programs, academic detailing, and tiered copays. With the exception of formulary use, generic substitution, and manufacturers' rebates, which all the plans have instituted, the types of interventions used by the different model types vary widely. More than half the pharmacy directors reported generic substitution, drug benefit design, and differential copays as very effective interventions used to control drug costs. CONCLUSIONS: The majority of pharmacy directors predict continued double-digit increases in drug expenditures over both the short term and the long term. Of the respondents, 91% reported that additional limits and/or exclusions to the benefit design would be necessary to control these increases. To continue providing a comprehensive drug benefit, 54% indicated that they would have to achieve sufficient cost savings in other areas to offset increases in drug costs.

Reporting the outcomes of care: effecting the transition from caring to comparing.

Accountability in health care has taken on new dimensions with the drive to base contracting and provider of care selection upon data driven "report cards." The measurement and development of reportable outcomes are driving providers to move their organizations from a focus not only on "caring" but to one highly cognizant of "comparing" in order to maintain market position and meet regulatory requirements. This article defines the areas of organizational transition required for reporting, and profiles the actions taken by three health care providers moving to an organizational style ready for "comparative" competition.

Impact of resident feedback on immunization outcomes.

OBJECTIVE: To investigate the effect on immunization levels of retrospective written feedback to residents regarding missed immunization opportunities. DESIGN: Randomized trial with control group. SETTING: Pediatric resident continuity clinic in an urban hospital-based primary care clinic. PARTICIPANTS: Thirty-two postgraduate level 2 and postgraduate level 3 pediatric residents. INTERVENTION: Monthly retrospective written feedback mailed to residents detailing their missed immunization opportunities and appointment failure rates over a 12-month period beginning in February 1997. MAIN OUTCOME MEASURES: The immunization level of 2-year-old children in the resident clinic was the main outcome of interest. Secondary outcomes included missed immunization opportunity rates and appointment failure rates. RESULTS: Postintervention immunization levels were 71.4% (95% confidence limits [CLs]: 63.2%, 78.7%) for patients from the intervention group and 68.5% (95% CLs: 60.8%, 75.4%) for patients from the control group. The immunization level for patients of both groups who had fewer than 2 visits during the second year of life was 47.2% (95% CLs: 38.2%, 56.3%). This compares with an immunization level of 78.1% (95% CLs: 66.0%, 87.5%) for patients from both groups who had 2 visits during the second year of life, and with an immunization level of 88.2% (95% CLs: 81.0%, 93.4%) for patients of both groups who had more than 2 visits during the second year of life (P<.001). CONCLUSIONS: In this setting, written retrospective feedback to residents was an ineffective strategy for improving immunization levels. Adequate follow-up during the second year of life is critical in achieving high immunization levels.