20 Years and Still Evolving

One year after the Academy of Managed Care Pharmacy (AMCP) was founded in 1988, the first issue of Drug Benefit Trends was published. The past 20 years have seen the evolution of managed care from infancy to, well, young adulthood-established but still changing. By showcasing innovative research and ideas on drug benefit design and delivery, DBT has long supported the mission of AMCP: “AMCP’s mission is to empower its members to serve society by using sound medication management principles and strategies to improve health care for all.”

Managed care pharmacy has improved access to medications and made drugs more affordable. It has put some cost and utilization controls as well as safety edits on unchecked prescribing. At its best, managed care supports the use of evidence-based medicine to improve clinical outcomes at the lowest possible cost, in essence seeking good value for every health care dollar spent. To be effective, managed care decision makers must sometimes say no to prescribers and patients or health care would quickly become unaffordable for most. I have heard medical directors of health plans lament just how difficult it is to say no, especially for cancer patients running out of treatment options. However, to physicians and community pharmacists, managed care decisions are often perceived as arbitrary or worse. Such cost-containment practices and other tactics are partly to blame for the looming shortage of primary care physicians.

For 20 years, DBT has chronicled industry trends in its “Trend of the Month.” In a September 1996 trend, health care professionals were asked when a national health care information infrastructure would be developed. Half said it would either take longer than 10 years or would never happen. Other trends have documented and/or projected continued growth in the use of generics, rising drug prices, use of formularies, health implications of rising obesity rates, growth in mail service outpacing retail pharmacy, phasing out of indemnity plans, greater use of prescription medications, increased use of specialty drugs, and more employers embracing wellness programs. Among the top 10 trends we expect to cover in 2009 and beyond are:
• Reliance on evidence-based medicine to guide clinical and managed care decision making.
• Promotion of health and wellness, not just disease prevention.
• Transparency throughout the health care system.
• Integration of medical and pharmacy information.
• Expansion and recognition of the role of pharmacists in improving health outcomes.
• Widespread use of e-prescribing and electronic health records.
• Further empowerment of patients through the Internet and other means.
• Greater roles for employers in shaping the drug benefit.
• Cost-effectiveness comparisons of medications and other therapies.
• Health care reform.

In an AMCP brochure titled “Thought Leaders in Health Care,” commemorating its 20th anniversary, the comments of David J. Brailer, MD, PhD, chairman of Health Evolution Partners, are especially insightful: “Few clinicians get to make lasting changes in how health care is delivered. This is what managed care pharmacy has done by introducing effectiveness, value, and safety into day-to-day prescribing. Your work gives us hope for a better health care system.”

Managed care principles of effectiveness, value, and safety provide a solid foundation as we prepare to debate the health care reform proposals of the Obama administration. To this list I would add flexibility to adapt, as managed care has done, to changing circumstances and new information-a criterion likely to be in short supply in, say, a government-run entity.
-Janice L. Zoeller