Magnifying the Impact of Clinical Practice by Automated Drug Reviews

About ten percent of total Medicaid expenditures are for drugs. Because a growing share of drug costs, and the consequences of their misuse, are being derived from tax dollars, those in government are seeking methods to hold drug-related expenditures down. The problems of high drug costs and drug misutilization have been clearly documented and indicate a need for effective drug utilization review (DUR). This need is especially acute in ambulatory patient populations, which suffer from a lack of good drug use control due to a general inability to reliably track ambulatory drug use patterns. The advent of government reimbursed drug benefits, which require compilation of all recipient drug claims regardless of the number of pharmacist or physician providers involved, and the pressures of drug cost control and drug use problems, have led to the creation and growth of a new health industry, the fiscal intermediary (FI). The FI combines expertise in electronic data processing (EDP) with knowledge of the drug delivery system. In this business milieu, new and unique opportunities have emerged for the clinically-trained pharmacist. This paper reviews the various levels of drug utilization review (DUR) employed by FIs, from elementary quantitative computer screens to highly sophisticated professional and peer review functions. The potential role of the clinically trained pharmacist in assuring the practice of optimal therapeutics across broad, ambulatory patient populations is illustrated. Specifically, the clinical pharmacist's functions in DUR problem identification, drug use criteria setting, DUR criteria evaluation, and as drug information resource person to the peer review networks, are discussed.