Journal of managed care pharmacy : JMCP
-
Pay for performance (P4P) is a business model in which health plans pay provider organizations (medical groups) financial incentives based on attainment of clinical quality, patient experience, and use of information technology. The California P4P program is the largest P4P program in the united states and represents a potential revenue source for all participating medical groups. The clinical specifications for the California P4P program are based on the national Committee for Quality assurance (NCQA), Health Plan Employer Data, and information set (HEDIS), and each clinical measure has its own benchmark. in 2005, participating medical groups were paid on the basis of 9 clinical measures that were evaluated in the 2004 measurement year. The cholesterol testing measure represented 4.44%-7.14% of the total P4P dollars available to participating medical groups from the health plans. ⋯ Preliminary data from 165 patients with diabetes managed in a CDCM program in a medical group operating under a small P4P financial incentive showed higher rates of LDL-C lab testing and goal attainment than from patients managed by routine care. Had these rates of LDL-C testing and goal attainment achieved in the CDCM program been extended to the entire P4P population with diabetes, this medical group would have generated incentive payments under the P4P program and ranked higher in publicly available quality scores.
-
Asthma still poses a substantial and unacceptable health and economic burden. The National Asthma Education and Prevention Program (NAEPP) guidelines for the management of asthma continue to evolve based on emerging clinical data, improving the understanding of asthma and approaches to its management. ⋯ Widespread adoption of evidence-based asthma management programs offers the opportunity for achieving and maintaining asthma control.
-
Medicare covers costs far more than 50% of all cancer patients, and most private payers follow Medicare's lead on coverage and benefits for cancer care. Medicare and private payers are legally required by federal statute to cover anticancer chemotherapeutic products based on U.S. Food and drug administration-approved labeling and indicate how off-label uses are covered. ⋯ Oncologists and their patients are left with difficult choices regarding not only the clinical efficacy of a treatment but also the financial considerations of the treatment.
-
The Medicare Modernization Act (MMA) has provided an opportunity for quality improvement organizations (QIOs) to partner with Medicare Part D plan sponsors. These new relationships have developed into a set of diverse projects, each approved by the Centers for Medicare & Medicaid Services. ⋯ This survey describes the promise of partnerships whose value will be fully realized in future years. The results of these early QIO initiatives will not be available until projects are evaluated, but QIOs and many Medicare Part D plans have established promising partnerships and have begun to share data for the purpose of assessing and improving plan and practitioner performance as well as patient engagement. Most projects are focused on ambulatory care, but some QIOs are addressing nursing home care and continuity of care between settings. Most ambulatory care projects are limited to prescription drug claims data, but a few plans are providing medical and lab data to QIOs in addition to drug claims. QIOs have historically worked almost exclusively with physicians and nurses but in many states are now engaged with colleges of pharmacy as well as with managed care and community pharmacists. QIO partnerships will provide managed care organizations and pharmacists with the opportunity for innovative quality improvement initiatives that might not otherwise be possible because of limitations of available data or resources. Pharmacists can use this document to review a wide array of options for working with QIOs and other partners in their market to design or strengthen their organization's medication therapy management and quality improvement programs. Managed care pharmacists may be particularly interested in the ability of QIOs to assist them in comparing their plans' performance with other national and regional plans.
-
Greater use of generic drugs, particularly as measured by the generic utilization or dispensing ratio (GDR), is an effective means of managing care by attaining the same clinical outcome as brand drugs but at lower cost. Health plans encourage members to use generic drugs through copayments that are lower than for brand drugs. Encouraging physicians to prescribe generic drugs in therapeutic selection continues to be an opportunity for health plans to produce drug cost savings without compromising safety or efficacy. ⋯ Physician practices that participated in the generic sampling program demonstrated an increase in the average GDR that was slightly greater than the increase in the comparison group of all other network physicians in each of the 2 measurement years, 2005 and 2006. Direct drug cost savings after subtraction of all administrative costs associated with the generic sampling program were estimated at $1,321 per participating physician in 2005 and $719 per participating physician in 2006. Members benefited from no copayment for the generic drug samples and from lower copayments for continued use of the generic drugs.