FORMULARIES AND COMMITTEE EVOLUTION THROUGH EMERGING MANAGED SYSTEMS OF CARE
Pharmaceutical care and the number of individuals who play a large role in its delivery have made rapid strides over the years. Part 1 of this series, published in the November 2004 issue of P&T, described how and when pharmacy and therapeutics (P&T) committees came into being and their specific roles over the years.
With changing times, pharmaceutical care in the U.S. has also changed. The concept of managed care came into existence as a measure to control the rising costs of delivering care, including medication costs. P&T committees came into being primarily in response to a proliferation of new, and sometimes significant, drugs entering the market.
Over the years, the needs and demands of patients have become more complex. As a result, P&T committees have continued to face increased responsibilities and challenges. In Part 2 of this series, we discuss the evolving role of P&T committees.
THE EXPANDING ROLE OF P&T COMMITTEES IN TODAY’S WORLD OF MANAGED CARE
The plethora of pharmaceuticals available and the ever-increasing complexities surrounding their safe and effective use make it necessary for health care organizations to have a sound program for maximizing rational drug use. The rising number and advancing age of older adults, the higher prevalence of multiple comorbidities, and the introduction of growing numbers of new and often costly medications to the market have made the functions of P&T committees more vital.
An ongoing, significant growth in the number of American citizens reaching 65 years of age and older will occur over the next few decades; the number is projected to reach 70 million by the year 2030. This rapid increase in the segment of the population that uses the largest number of prescriptions, coupled with the constantly mounting costs of pharmaceutical therapy, makes it imperative for health care organizations to develop a sound approach for evaluating new pharmaceuticals—their costs and the economic, clinical, and humanistic outcomes from their use.
In the early 1980s, managed care organizations (MCOs) adopted the use of P&T committees to create medication formularies (preferred drug lists) for the ambulatory setting. At that time, drug formularies were created primarily to designate preferred drugs based on available safety, efficacy, and cost information. Formularies were also used as leverage to obtain discounts or rebates from pharmaceutical manufacturers for these preferred drugs.
When the fee-for-service model was the primary reimbursement method for health care services, there was little incentive to control costs, especially for ambulatory patients. Patients paid cash for their prescriptions. It was only when health plans began to attach medication riders to their medical coverage that members began to see their out-of-pocket drug costs shrink to the cost of a minimal co-payment. Early formularies were considered to be “open,” and there were few restrictions on coverage. Clinical efficacy and safety were the primary considerations for medications to gain formulary approval.
As the cost of prescription drugs began to rise in the middle to late 1980s, the emergence of restrictive formularies, generic substitution, and Drug Utilization Review (DUR) as a means to control pharmaceutical costs became commonplace in managed care. Today, MCOs face increasing competition in many regions, and this adds to the pressure to control costs even more. At the same time, MCOs are facing escalating demands from various government bodies and employers to have authentic quality data on the services that they provide to their members. As a result, MCOs, hospitals, and other health care organizations must control costs as well as document the delivery of high-quality care. canadian pharmacy cialis
There has been a gradual evolution in the purpose of the P&T committee, as described in Part 1 of this series. As more and more medications are introduced, including expensive biotechnology-derived products, and as the U.S. population ages, the role of P&T committees is expected to become more multifaceted.