CEO Blog 03/01/19
Susan A. Cantrell, RPh, CAE
It’s a truism that the U.S. health care system is complex and expensive. Everyone from patients, payers and politicians agree that costs are too high and care delivery is difficult to navigate. We do too. But sometimes in the heated debate over how to improve the system, fingers are pointed and targets identified without understanding the full ramifications of proposed solutions.
It’s not as simple as saying: let’s just get rid of all negotiated rebates; or impose an international benchmark price for pharmaceuticals; or eliminate utilization management tools such as prior authorization.
Waving a magic wand won’t make costs automatically go down, or immediately smooth the patient experience.
But there are things that can be done to improve the system. And in this vein, I firmly believe the evidence-based practices of managed care pharmacy are part of the solution. Our practices are time-tested to optimize health care outcomes and lower costs.
This is most evident in a fundamental managed care pharmacy tool known as the tiered formulary.
The formulary has at its heart one of the most promising concepts in health care today: value-based care.Pharmacy and therapeutic (P&T) committees, which are made up of diverse health care professionals including pharmacists and physicians, identify those medications that offer the best value in terms of outcomes and costs. These products are then placed on formulary tiers with different copayments to incentivize patient and provider utilization behaviors.
Our goal, again, is to ensure the best health outcomes and the best use of our health care dollars — the very essence of value-based care.
Managed care pharmacy also brings order to what could otherwise be an overwhelming and confusing pharmaceutical marketplace. We applaud the current wave of biopharmaceutical innovation that is producing so many new and curative therapies every year. But we also know that health care resources are not unlimited, and someone must assess the clinical and economic value that new medicines bring to patients, providers and payers alike.
This is where another managed care pharmacy practice comes into play: the use of prior authorization.
Based on sound science, prior authorizations are applied to products that are more costly than other viable alternatives. This practice really boils down to common sense: why use the latest, most expensive therapy first when another equally, if not more, effective alternative is available that will likely be just as effective in treating the patient, and at a much lower cost to the patient and the payer.
That’s what prior authorization and the formulary process are about. These get to the heart of managed care pharmacy principles.
Managed care pharmacy professionals are dedicated to improving people’s lives by making sure they can obtain the medications needed to be healthy and productive members of society. I like to say our corner of health care is small but mighty. AMCP’s roughly 8,000 members design and manage the pharmacy benefits of nearly 300 million Americans who receive health coverage.
We take this responsibility very seriously. And we are part of the solution.