Appropriate Uses of Prescription Information by Managed Care Organizations
Where We Stand:
The Academy of Managed Care Pharmacy (AMCP) believes that prescription information, whether individually identifiable by patient or prescriber or aggregated without identifying specific individuals, should be available for use by managed care organizations. When used appropriately, this information can help promote responsible prescription drug use, protect patient safety and reduce overall health care costs. However, AMCP does not support the use, sale or purchase of this information with the intent to use it for marketing or other commercial purposes.
Pharmacists and managed care organizations use patient‐identifiable pharmacy information for treatment‐related activities such as health promotion and wellness, disease management, quality assurance, quality improvement, research, fraud, waste and abuse, and drug utilization review. In addition, pharmacists rely on this information to protect patients against inappropriate medication uses through medication therapy management (MTM) programs, which are a required set of services under Medicare Part D, and also a mainstay of clinical quality management across all other market segments. Through MTM, pharmacists can better evaluate patients’ drug therapy needs, identify and prevent adverse drug reactions and medication errors, identify and close key gaps in care, manage chronic drug therapy, and ensure continuous monitoring and follow‐up. Patient‐identifiable prescription information is also used to communicate formulary and benefit designs to maximize a beneficiary’s pharmacy benefit.
One of the most important uses of prescriber‐and patient‐identifiable information is in drug utilization review (DUR). DUR programs play a key role in helping pharmacists and managed care organizations understand, interpret, and improve the prescribing, administration, and use of medication. Many states require that pharmacists conduct medication reviews at the point‐ of‐sale (Concurrent DUR) for outpatient prescriptions to protect against drug‐drug interactions, encourage generic and therapeutic substitution, and identify clinical abuse or misuse. Managed care organizations also use prescription claims history to monitor patterns of prescribing, dispensing, and consumption of medications to ensure cost‐effective care and compliance with nationally–recognized best practices and consensus guidelines. DUR programs also help managed care organizations monitor for fraud, waste, and abuse in the health care system. DUR programs represent a responsible and prudent use of prescriber‐and patient‐identifiable prescription information which encourage appropriate prescription drug use and also prevent unnecessary health care spending.
“Academic” or “counter” detailing programs work in concert with DUR programs to encourage proper prescription medication use. Programs at the state level have successfully reduced overall spending on prescription drug costs. Managed care pharmacists working in an academic detailing program can use prescriber‐identifiable prescription information in order to tailor their message to be of greatest value to prescribers and patients. The programs train pharmacists and other health care professionals to offer unbiased, objective information to prescribers about prescription drugs and other available therapies. A well‐designed program independently evaluates the clinical effectiveness of different treatments for a particular disease state based on available research, promotes evidence‐based and cost‐effective treatments, as well as encourages generic utilization. This academic detailing approach offers prescribers a perspective that can differ from visits by pharmaceutical sales representatives, which are often promotional in nature. These programs can be a component of a health plan’s or PBM’s overall DUR program, or a separate program funded by the government and targeted to participating providers in public benefit programs, such as Medicaid or state employees’ health benefits plans.
Research is another area where use of patient‐identifiable prescription information is appropriate. Managed care organizations use claims data, including prescription information and other relevant data, to perform outcomes research, comparative effectiveness research, and other health care studies. Outcomes research efforts provide value to members, providers, and payers by addressing gaps in knowledge such as those relating to patient health care outcomes, cost‐effectiveness, adverse drug events, medication non‐adherence, and value of benefit design. In addition, managed care organizations with integrated health information records are able to review prescription claims data and compare it with the rest of a patient’s health record. Many times, side effects of prescription medication do not manifest until the medication is in wide use by a variety of patients outside of controlled clinical trials. This type of research can help plan administrators identify trends (e.g., weight gain) or adverse health events (e.g., heart attack) among a group of patients taking a specific medication. This information can then be used either to communicate concerns with prescribers or control patient access to a high‐risk treatment.
Lastly, patient‐identifiable data is also a critical component to ensuring safe and effective patient care transition from hospitals and other inpatient settings to the home. More and more, managed care pharmacists are actively participating as a vital member of the care management team via new models of delivery such as the ‘patient‐centered medical home.’ As part of this work, pharmacists in many organizations are working to decrease the current high prevalence of hospital readmissions, particularly in the Medicare population, through more active monitoring and intervention with patients and/or caregivers during the immediate post‐discharge period. In doing so, they can better ensure that proper medications are being prescribed and consumed, that duplicative and/or conflicting therapies are mitigated, and that patients are well educated and engaged in their post‐admission care.
While the use of prescription information can provide many positive benefits and promote appropriate prescription drug use, AMCP is opposed to the use, sale, or purchase of prescription drug information for marketing and commercial uses. Access to prescription information allows salespeople to target their marketing efforts in an attempt to maximize market share for a product, not necessarily to provide unbiased educational information. Materials and educational sessions sponsored by pharmaceutical manufacturers tend to focus only on one product, instead of all therapies involved in treating a particular medical condition. This can lead to unnecessary prescribing of medications that can have less expensive generic or therapeutic counterparts, driving up health care costs.
AMCP supports the use of prescription information in a responsible manner. This information is a critical component of DUR and academic detailing programs, as well as outcomes research. When used properly, prescription information can help maximize patient health care outcomes and ensure the affordability of a prescription drug benefit.
AMCP position statement on the Use of Technology in the Health Care System
AMCP Where We Stand series: https://www.amcp.org/policy-advocacy/policy-advocacy-focus-areas/where-we-stand-position-statements
Revised by the AMCP Board of Directors, April 2014
Approved by the AMCP Board of Directors, June 2009