AMCP Partnership Forum: Optimizing Prior Authorization for Appropriate Medication Selection.

Prior authorization (PA) and step therapy (ST) are utilization management tools that have been in use by managed care organizations for decades. These processes require that health care providers obtain advanced approval to qualify a specific product for coverage from a health plan before it is delivered to the patient. These tools are intended to ensure that patients have access to evidence-based medications while payers remain good stewards of limited health care resources. PA and ST are growing in use to support appropriate use of medications and manage associated costs but may pose challenges related to administrative burden and access to care. In June 2019, the Academy of Managed Care Pharmacy (AMCP) conducted a multistakeholder forum to identify processes for optimizing PA and ST utilization management programs. Health care leaders representing academia, health plans, integrated delivery systems, pharmacy benefit managers, employers, federal government agencies, national health care provider organizations, and patient advocacy organizations participated in the forum. Participants explored current operations of these programs, evaluated stakeholder perspectives on opportunities to improve these programs, and provided recommendations for next steps. They also reviewed current federal and state legislative and regulatory activities to reform PA and ST processes and offered guidance to support program improvements. The goal of the forum was to gather stakeholder input to inform the development of recommendations to improve efficiencies around PA and ST processes; provide recommendations to address administrative burdens; increase the visibility of the clinical and economic value of PA and ST utilization management programs; collect, review, and disseminate data-driven, real-world experiences of PA programs that support clinical and economic value; collect and disseminate best practices around PA appeals and denial processes; and improve channels of communications between health insurance providers, health care professionals, and patients to minimize care delays and improve clarity of coverage authorization requirements. DISCLOSURES: This AMCP Partnership Forum was sponsored by Mallinckrodt Pharmaceuticals, Merck, the National Pharmaceutical Council, and Takeda. These proceedings were prepared as a summary of what occurred at the forum to represent common themes; they are not necessarily endorsed by all attendees nor should they be construed as reflecting group consensus.

Interest of a drug and therapeutics committee for the operation of a hospital in a developing country: Dapaong, Togo.

The department of pharmacy of the Regional Hospital of Dapaong is responsible for delivery of health products. We sought to assess the department's avoidable costs to optimize the hospital's drug policies and thereby improve patient care. This cost-forecasting study is intended to convince the hospital staff of the utility of setting up a drug and therapeutics committee and more particularly of developing a drug handbook for use within the public health institutions of the Savanna region. This prospective study seeks to improve the efficiency, quality, and availability of medicines by listing the references currently available at the Regional Hospital to demonstrate the percentage of duplicates and to show the references currently unavailable via "lost" sales. A retrospective study then estimated the loss of income from sales due to expired drugs. Our studies indicate that optimized management of the pharmacy would result in a potential gain of 14,914,397 FCFA, that is, 22,770 €. This significant savings could be used to improve the quality of care and promote quality assurance at the CHRD. The elimination of duplicates would allow the purchase of currently unavailable pharmaceutical classes (12,369,701 FCFA, that is, 18,885 € for reinvestment), and multidisciplinary collaboration with prescribers could reduce the losses associated with expired drugs (2,544,696 FCFA, or 3,885 €). These changes would improve the matching of the drugs prescribed at the CHRD and those delivered by the pharmacy.

Development of a complementary and alternative medicine (CAM) pharmacy and therapeutics (P&T) subcommittee and CAM guide for providers.

OBJECTIVE: The objective was 2-fold: (1) to evaluate the feasibility and value of developing a Pharmacy and Therapeutics (P&T) subcommittee aimed at scientifically evaluating complementary and alternative medicine (CAM) products for an integrated managed care organization (IMCO) and (2) to assess provider acceptance and usefulness of a CAM guide. METHODS: Three factors drove the decision to form a CAM P&T subcommittee to evaluate current commonly used CAM products: (1) physicians, pharmacists, and dieticians expressed a desire for an easy-to-use, scientifically based mechanism for evaluating the ever-increasing number of CAM products; (2) Intermountain Health Care Health Plans (Health Plans), the insurance division of this IMCO, offers access to certain CAM products to its members at a discounted price in an effort to remain competitive with other IMCOs; and (3) this IMCO owns and operates more than a dozen community pharmacies that sell CAM products. Some IMCO clinicians believed an efficacy and safety review of the products offered through the organization was warranted. Subcommittee members included clinical pharmacists (IMCO and university), pharmacy directors, a community pharmacist, practicing physicians (from the drug P&T committee), a medical director, dieticians and nutritionists, and a representative from the Health Plans sales department. The primary outcome was the development of a CAM guide listing recommendations for use of CAM products. Outcome measures included survey results (survey sent with guide to physicians and (pharmacists) regarding acceptance and usefulness of the guide. RESULTS: The CAM P&T subcommittee met monthly to evaluate current commonly used CAM products. A CAM guide was developed in paperback and electronic versions. The electronic version was downloadable to handheld devices. Thousands of CAM guides were disseminated to IMCO-employed physicians, network pharmacies, dieticians, and nutritionists affiliated with this managed care organization. A survey that accompanied distribution of the first CAM guide in 2003 showed that 89% of physicians and pharmacists felt that the guide would be somewhat or very helpful as a counseling aide; the remainder was unsure. A second CAM guide was disseminated one year later, in 2004. The accompanying survey showed that 78% of physicians and 97% of pharmacists felt that the guide would be somewhat or very helpful as a counseling aide; 7% of physicians and 3% of pharmacists felt the guide would be unhelpful. CONCLUSION: A CAM guide developed through the work of a subcommittee of the P&T committee of this IMCO appears to be widely accepted by pharmacists and physicians. A CAM guide should be easy to use and available online with the ability to download to a handheld device.

Access to new cardiovascular therapies in Canadian hospitals: a national survey of the formulary process.

BACKGROUND: Access to new therapies in hospitals depends upon both clinical trial evidence and local Pharmacy and Therapeutics (P&T) committee approval. The process of formulary evaluation by P&T committees is not well-understood. OBJECTIVES: To describe the formulary decision-making process in Canadian hospitals for cardiovascular medications recently made available on the Canadian market. METHODS: Postal survey of hospital pharmacy directors in all Canadian hospitals with more than 50 beds. Target drugs included abciximab, enoxaparin, dalteparin, clopidogrel, eptifibatide and tirofiban. RESULTS: Of 428 surveys mailed, responses were received from 164 P&T committees representing 350 hospitals for an effective response rate of 82%. While physicians make up the largest proportion of committee membership, pharmacists play an influential role. Information most commonly cited as influencing formulary decisions included published clinical trials (97%), regional guidelines (90%), pharmacoeconomic data (84%), decisions at peer hospitals (73%) and local opinion leaders (60%). However, this information was often not required on formulary applications. Approval timelines varied widely for target medications but there were no regional, hospital or P&T committee characteristics that were independent predictors of early formulary application or approval. CONCLUSIONS: There is wide variability in the time taken for Canadian institutions to adopt new cardiovascular therapies, which is not explained by regional, hospital or P&T committee characteristics. Standardization of the formulary application and evaluation processes, including sharing of information amongst institutions, would lead to broader understanding of the applicable issues, more objectivity and improved efficiency.

Creating a hospice pharmacy and therapeutics committee.

Implementing a Pharmacy and Therapeutics Committee (P&T) as a management strategy for Hospice of the Bluegrass in Lexington, Kentucky, has proven to be effective in reducing costs and improving patient outcomes. Early efforts of the committee yielded the establishment of protocols and guidelines, educational programs, pharmacy newsletters for nurses, and patient education material. In the spring of 2000, Hospice of the Bluegrass developed a preferred drug list (PDL) consisting of the medications it considered essential for effective pain and symptom control. The addition of a clinical pharmacist and a P&T committee has resulted in significant cost savings and improved pharmacotherapeutic care for patients of Hospice of the Bluegrass. This model is an option for any hospice looking to achieve the same outcomes.

Pharmacoeconomics and clinical practice guidelines. A survey of attitudes in Swedish formulary committees.

BACKGROUND: Swedish formulary committees are expected to influence prescribing practice by establishing and issuing drug lists and clinical practice guidelines, particularly now that financial responsibility for prescription drugs has been transferred from the national to the county council level. OBJECTIVE: The purpose of this exploratory study was to identify the information sources and decision criteria that individual committee members perceive as important in establishing clinical practice guidelines. Moreover, obstacles to the increased use of pharmacoeconomic evaluations in decision-making were also identified. DESIGN AND SETTING: Data were gathered through a survey questionnaire administered in 1998 to members of central formulary committees throughout Sweden, as determined by a national register. PARTICIPANTS: 312 members of central formulary committees, of whom 69% responded. RESULTS: Treatment policies/guidelines supplied by government authorities, or found in reviewed journals, are considered the most important sources of information, and criteria associated with costs and effects are considered the most important decision criteria. The members' years of experience and their professions affect their assessments of information sources, whereas education in health economics affects their assessments of decision criteria. Committee members voiced an interest in pharmacoeconomic issues, but warned that there was neither sufficient competence among committee members nor an adequate supply of relevant studies. Furthermore, a majority of the members identified difficulty in translating study results into clinical practice guidelines and limited possibilities in comparing studies as obstacles to the increased use of pharmacoeconomic evaluations. CONCLUSIONS: The results of this survey may be useful in designing future economic evaluations and when presenting and diffusing study results.

Activities, functions, and structure of pharmacy and therapeutics committees in large teaching hospitals.

The results of a survey on the activities and functions of hospital-based pharmacy and therapeutics (P&T) committees are presented. Questionnaires were mailed to the pharmacy director or the person responsible for the pharmacy's drug information service at 267 teaching hospitals throughout the United States in 1994 and 1995. The survey questions covered P&T committee composition, functions, roles of members, policies and procedures, and formulary-maintenance activities. The overall response rate was 70%. The mean number of members on the P&T committees was 19.3, of whom 91% were allowed to vote. There was an average of 12.3 physicians on the committees. Each P&T committee had at least one pharmacist member, with an average of 3.2 pharmacist members; 69.5% of the institutions reported having a committee secretary, who was almost always a pharmacist. On almost all committees, pharmacists wrote the minutes, prepared the formulary review documents, and were responsible for monitoring formulary activities outside the meeting. The P&T committee functioned in a very formal manner. Most (87.7%) of the respondents reported that their institutions had a closed formulary. At all hospitals, the attending medical staff could request additions to the formulary, but at only 62.4% of the hospitals could pharmacy staff make a similar request. The committees were active in changing the formulary. P&T committees in large teaching hospitals are active in formulary management, are large and diverse, and consist mainly of physicians, although pharmacists play an important role in the meetings.

Pharmacy and Therapeutics committee. Cost-containment considerations.

The Pharmacy and Therapeutics committee is a frequently used mechanism for health care organizations to meet mandated standards. The control that the committee has over the formulary is often seen as a potential way of controlling the expenditures for drugs. As the Pharmacy and Therapeutics committee is the means for the clinical staff to have an effect as to what agents are available to practitioners, it is incumbent on the committee members to have a clear idea of what their role should be in cost containment. An important concept that impacts on cost is that optimal health benefit is not necessarily the result of maximum expenditure. The welfare of the patient is paramount to all in the health care field; however, it is the task of clinicians to determine what constitutes optimal health benefit and to act as agents of the patient. Clinicians must maintain patient care as their top priority. Although health care expenditures are an extremely important issue, quality of patient care cannot be subrogated to a secondary concern.

Grampian Health Board's joint drug formulary.

OBJECTIVE: To develop a model for creating a joint general practice-hospital formulary, using the example of ulcer healing drugs. DESIGN: A joint formulary development group produced draft guidelines based on an earlier hospital formulary, which were sent to interested local general practitioners for consultation. Revised guidelines were then drawn up and forwarded to the health board's medicines committee for approval and distribution. SETTING: Grampian Health Board. SUBJECTS: Nine members of joint formulary development group plus local general practitioners who were invited to comment on a list of 11 ulcer healing drugs. MAIN OUTCOME MEASURE: Degree of coincidence of drugs selected by hospital doctors and general practitioners. RESULTS: The ulcer healing drugs selected by the panel of general practitioners and by hospital doctors were highly coincident. The cost of one day's treatment with drugs varied considerably between hospital and general practice--for example, one drug cost 46p in hospital and 1 pounds in general practice and another cost 1.26 pounds in hospital and 1.01 pounds in general practice. Overall, six drugs cost more in hospital and five cost more in general practice. CONCLUSIONS: A joint formulary for use in hospitals and general practice in a health board can be devised fairly simply by consultation as virtually the same drugs are used in both types of practice. It should influence the health board's expenditure on drugs and affect the choice of drugs when a patient is discharged from hospital or is referred to any hospital in the region.

The management of a hospital formulary.

This paper describes the management of a hospital formulary that is operated by voluntary co-operation of prescribes. The organizational and philosophical factors associated with the formulary management system in a major teaching hospital environment are discussed. A combination of educative, re-educative, persuasive and facilitative strategies is used to influence prescribing behaviour. Both passive and active methods, including face-to-face intervention methods are practised. The formulary is reinforced with an extensive pharmacy monitoring operation which stimulates facilitative dialogue between pharmacists and prescribers and encourages medical self-audit and peer review. Evidence of compliance with recommended policies, and consequent control of drug expenditure are presented.

Improving pharmacy and therapeutics committee operations.

A panel discussion of various aspects of the operations of pharmacy and therapeutics (P & T) committees is presented. Pharmacy and therapeutics committee operations in various types and sizes of hospitals are described. Ways of stimulating physicians' interest in P & T committee activities, difficult problems faced, scope of issues dealt with by P & T committees, functions of P & T subcommittees, the value of drug information from pharmaceutical representatives, and the influence of research funds from the pharmaceutical industry on committee decisions are discussed. Panel members also present their views on therapeutic alternates, FDA-nonapproved use of drugs, and counter-detailing. Finally, suggestions for improving P & T drug evaluations, cost-containment issues, and the authority of P & T committees are discussed. A well-prepared agenda, good educational material, active members, and strong leadership are important for successful P & T committee operations.

Cost containment through P & T committee drug utilization review.

Provoked by changes that are occurring in health care, hospitals are currently formulating and implementing strategies to identify and control costs while maintaining the highest quality of care. Because drug costs account for a significant proportion of the hospital supply budget (5 to 10%), there is an increased need for the P & T Committee to become involved in the cost containment effort. This article will demonstrate how an existing program of drug utilization review (DUR) has reduced drug expenses without sacrificing the quality of care or imposing unnecessary restrictions on formulary items. Furthermore, implementation of the DUR program has not resulted in conflict between pharmacy, medical, nursing or administrative staffs within the institution.