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Value-based management of specialty drugs: practical considerations and implications for pharmacy
- Source :
- The American journal of managed care. 27(5)
- Publication Year :
- 2021
-
Abstract
- OBJECTIVES Concerns about high and rising drug prices have prompted a call to manage prescription drugs according to their value. Although not all proposals referred to as "value based" are well suited to advance this mission, health plans must select among them under the influence of competing demands and constraints of their market and nonmarket environments. To understand the implications for health policy, we sought to explore how health plans might select among and implement these approaches for specialty pharmacy (SP) under the incentives and barriers that these conditions create. STUDY DESIGN An experienced research team conducted a qualitative study with Blue Cross Blue Shield health plans interested in implementing value-based SP management. METHODS Plans'objectives, operational strategies, and factors influencing their ability to execute on these strategies were elicited in 3 focus groups. RESULTS Four business objectives were identified, centering on spending levels, spending variability, access to new treatments, and evidence generation for new treatments. Supporting operational strategies included increased utilization management (UM), provider and patient engagement, expanded data analytics, and adjustments to staffing models. Factors that influence their ability to act on these strategies include regional and national scale, strength of provider network relationships, disease management capabilities, business and data silos, and potential legislative actions to limit UM. CONCLUSIONS Health plans' preferences for different forms of SP management may not be aligned with policy objectives, particularly those that advance innovation. Policy makers should consider market and nonmarket factors that influence these preferences, including the need to mitigate spending variability and generate evidence to guide coverage decisions.
- Subjects :
- Prescription Drugs
business.industry
Health Policy
Staffing
Nonmarket forces
Pharmacy
Blue Cross Blue Shield Insurance Plans
United States
Incentive
Specialty pharmacy
Pharmaceutical Services
Medicine
Humans
Marketing
Disease management (health)
business
Utilization management
Health policy
Qualitative research
Subjects
Details
- ISSN :
- 19362692
- Volume :
- 27
- Issue :
- 5
- Database :
- OpenAIRE
- Journal :
- The American journal of managed care
- Accession number :
- edsair.doi.dedup.....7982c08f70949906084622a99e9efc5e