Milestones in managed care pharmacy.

Managed care pharmacy has a relatively short history, but one that is defined by significant achievements. Since the late 1960s, managed care pharmacists have applied their unique skills to formulary management, clinical programs, benefit design, and contract negotiations to support patient access to life-saving therapies, while also ensuring cost-effective use of limited health care resources. Key milestones include establishing the pharmacy benefit as an essential component of the U.S. health care system, launching the Medicare Part D program, and expanding medication therapy management services. The year 2020 brings another milestone-the 25th anniversary of AMCP's flagship publication, the Journal of Managed Care + Specialty Pharmacy. This year also serves as an inflection point. As managed care pharmacy professionals prepare for change and the challenges ahead-including the imperative to address the rising costs of health care and health disparities-the use of evidence, utilization management strategies, and innovation will support our continued success. DISCLOSURES: No funding supported the writing of this commentary. The authors have nothing to disclose.

Reflections on the Formulary System from 1997 to the Present.

DISCLOSURES: No funding was received for the writing of this reflection. Avey is a member of the AMCP Foundation and has recently retired from MedImpact Health Systems, where he served as Vice President of Specialty Clinical Solutions.

PRACTITIONER UPDATE.

OBJECTIVE: To review the development and implementation of prescription formularies by managed care organizations, identify their current applications, and recognize future trends in the managed care pharmacy environment. DATA SOURCES: Current journal articles and texts regarding the use of formularies and the managed care environment. DATA SYNTHESIS: Not applicable. CONCLUSION: Formulary systems have proven to be a valuable means to control the pharmacy benefit and can be expected to expand in both scope and sophistication.

The Historical Development of Value-Based Care: How We Got Here.

The original architects of Medicare modeled the payment system on the existing fee-for-service (FFS) structure that historically dominated the health-insurance market. Under the FFS paradigm, health-care expenditures experienced an exponential rise. In response, the managed care and capitation models of health-care delivery were developed. However, changes in Medicare reimbursement, along with an increasing volume of orthopaedic procedures and escalating implant costs, call into question the cost-effectiveness of this service line. The success of the Medicare Acute Care Episode (ACE) Demonstration Project proved the feasibility of value-based care and ushered in a new era of bundled payment initiatives.

Perícias, acidentes e hérnias no contexto do direito à saúde, Colômbia 1915-1946 / Expertise, accidents and hernias in the context of the right to health, Colombia 1915-1946

Para a maioria dos médicos, a apreciação da incapacidade em casos de acidentes de trabalho ou doenças profissionais era um assunto bastante relativo e juízo clínico, subjetivo e pouco satisfatório em questões jurídicas. No esquema da lei de acidentes de trabalho, eles tinham a função de julgar o nexo de causalidade entre o acidente e a doença, ao mesmo tempo que indicar o tipo de compensação econômica que devia receber o trabalhador. Para isto, deviam ir além do conhecimento científico e compreender a multiplicidade de fatores sociais que envolvem o infortúnio no mundo do trabalho. Neste artigo, analisam-se fontes colombianas da primeira metade do século XX, sobre questões como fisiologia do trabalho, fadiga, risco profissional, acidentes de trabalho, doenças profissionais, etc. Pretende-se avançar na compreensão da maneira como o campo de saber médico foi configurando uma espécie de deontologia pericial nos casos de acidente de trabalho, porém, se concentra nas hérnias, um dos estigmas típicos do mundo do trabalho (AU)

For most physicians, the assessment of disability in cases of work accident or occupational disease is very relative matter, and clinical judgments are subjective and unsatisfactory in legal settings. Work accident legislation gives them the task of deciding on any causal links between accident and disease and indicating any economic compensation that should be awarded. They must therefore reach beyond their scientific knowledge to understand the multitude of social factors that underlie these problems in the world of work. In this article, we analyze Colombian sources from the first half of the 20th century on the physiology of labor, fatigue, professional risk, work accidents, occupational diseases, among other issues. The aim is to advance understanding of how the field of medical knowledge established an ethical approach for experts in cases of occupational accidents, focusing on hernias, typical misfortunes of the world of work (AU)

Regulated wet nursing: managed care or organized crime?

Wet nursing was widely practiced from antiquity. For the wealthy, it was a way to overcome the burdens of breastfeeding and increase the number of offspring. For the poor, it was an organized industry ensuring regular payment, and in some parishes the major source of income. The abuse of wet nursing, especially the taking in of several nurslings, prompted legislation which became the basis of public health laws in the second half of the 19th century. The qualifications demanded from a mercenary nurse codified by Soran in the 2nd century CE remained unchanged for 1,700 years. When artificial feeding lost its threat thanks to sewage disposal, improved plumbing, the introduction of rubber teats, cooling facilities and commercial formula, wet nursing declined towards the end of the 19th century.

Are we there yet? Seizing the moment to integrate medicine and public health.

Multiple promising but unsustainable attempts have been made to maintain programs integrating primary care and public health since the middle of the last century. During the 1960s, social justice movements expanded access to primary care and began to integrate primary care with public health concepts both to meet community needs for medical care and to begin to address the social determinants of health. Two decades later, the managed care movement offered opportunities for integration of primary care and public health as many employers and government payers attempted to control health costs and bring disease prevention strategies in line with payment mechanisms. Today, we again have the opportunity to align primary care with public health to improve the community's health.

How much do hospitals cost shift? A review of the evidence.

CONTEXT: Hospital cost shifting--charging private payers more in response to shortfalls in public payments--has long been part of the debate over health care policy. Despite the abundance of theoretical and empirical literature on the subject, it has not been critically reviewed and interpreted since Morrisey did so nearly fifteen years ago. Much has changed since then, in both empirical technique and the health care landscape. This article examines the theoretical and empirical literature on cost shifting since 1996, synthesizes the predominant findings, suggests their implications for the future of health care costs, and puts them in the current policy context. METHODS: The relevant literature was identified by database search. Papers describing policies were considered first, since policy shapes the health care market in which cost shifting may or may not occur. Theoretical works were examined second, as theory provides hypotheses and structure for empirical work. The empirical literature was analyzed last in the context of the policy environment and in light of theoretical implications for appropriate econometric specification. FINDINGS: Most of the analyses and commentary based on descriptive, industry-wide hospital payment-to-cost margins by payer provide a false impression that cost shifting is a large and pervasive phenomenon. More careful theoretical and empirical examinations suggest that cost shifting can and has occurred, but usually at a relatively low rate. Margin changes also are strongly influenced by the evolution of hospital and health plan market structures and changes in underlying costs. CONCLUSIONS: Policymakers should view with a degree of skepticism most hospital and insurance industry claims of inevitable, large-scale cost shifting. Although some cost shifting may result from changes in public payment policy, it is just one of many possible effects. Moreover, changes in the balance of market power between hospitals and health care plans also significantly affect private prices. Since they may increase hospitals' market power, provisions of the new health reform law that may encourage greater provider integration and consolidation should be implemented with caution.

The big question: what is the most pressing health crisis and how can it be solved?

It is perhaps the single most elusive question today-how to manage and care for the billions of people who will fall ill this year, often terminally, in nations rich and poor? In so many cases the status of health is a purely financial question. Far too often poor health is simply a question of ignorance or the absence of drugs, medical facilities, clean water and a healthy environment. To help inform the debate, World Policy Journal asked a panel of experts to weigh in on what they see as the most pressing health crisis today and how it can be solved.

The history of managed care and the role of the child and adolescent psychiatrist.

The child and adolescent psychiatrist cannot practice in today's world without interacting with the world of insurance and managed care. This article reviews the history of the development of the managed care industry. It also examines the variety of roles clinicians play, whether as members of physician networks, as a peer or utilization reviewers, or as medical directors. The skills required of the physician employee and the contractual and ethical concerns are discussed.