Congress passed the Health Insurance Portability and Accountability Act (HIPAA) in 1996. Within that Act are privacy provisions with which covered entities (including all health plans, health care providers and health care clearinghouses [e.g. PBMs] that transmit any health information in electronic form must comply. HIPAA rules provide guidance to covered entities about how to comply with the Act.
Health plans, employers and government-sponsored health care programs are focusing their attention on optimizing patient outcomes through the use of medications that have established evidence of efficacy and safety, while providing the highest value.
Population health management (PHM) is a key concept in managed care. Improving population health, enhancing the patient experience, and reducing per capita cost are the primary goals of a philosophy called the Triple Aim. PHM extends beyond healthcare organizations, requiring the cooperation of other types of institutions, such as public health departments and social service entities.
The Academy of Managed Care Pharmacy (AMCP) is concerned about the harmful effects that medication stockpiling could have on individual patients, as well as the population as a whole. The Academy is providing this document as a means of educating the public about the unintended and potentially harmful results of medication stockpiling, and to remind health care providers of the role that they play in preventing these occurrences.
Formulary management is an integrated patient care process which enables physicians, pharmacists and other health care professionals to work together to promote clinically sound, cost-effective medication therapy and positive therapeutic outcomes. Effective use of health care resources can minimize overall medical costs, improve patient access to more affordable care and provide an improved quality of life.
Drug utilization review (DUR) is defined as an authorized, structured, ongoing review of prescribing, dispensing and use of medication. DUR encompasses a drug review against predetermined criteria that results in changes to drug therapy when these criteria are not met.
The purpose of this paper is to explain how managed care organizations (MCOs) are able to secure lower drug prices from pharmaceutical manufacturers as part of an effort to control drug expenditures.