Response needs to be a minimum of 300 words Do you think utilization management

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Explanation / Answer

For payers, utilization management is much simpler on the pharmacy benefits side than on the medical side.

Medical benefits include products that are covered and provided commensurate to some type of physician or practitioner service. This can create confusion in tracking and monitoring. “We may have, actually, 2 products that share a J code,” . “When that happens, there’s not an easy way for the plan to figure out what was actually provided. When you add to this mix the different strengths and dosage units of a product, it creates a bit of a challenge to manage drugs on the medical side. Historically, there has not been a lot of management on the medical side.”

The pharmacy side is easier. Phar­macy benefit managers (PBMs) can capably handle tracking and monitoring in real time. All claims from pharmacy channels run through the PBM contracts, and all drugs are tracked by national drug codes. Drugs can be managed down to their individual unit, strength, dosage, and package size. Data management and reporting can be easily handled.

“Also, if we want to cover a drug that’s oral, but not cover a nasal route, then we can do that. That’s not a luxury we have on the medical side with the current systems,”

Much of utilization management involves benefit design, which encompasses:

Additional utilization management options include step-edits, quantity limits, use of preferred products, use of tiered formularies, cycle management, oncology first-fill programs, buy-and-bill management, and prior authorization.

“The degree to which utilization management is applied can have a significant impact on physician practices,” Mr Kenney noted. “From a plan perspective, ideally, what we want is not to disrupt the practice, not to disrupt the patient flow, but to put reasonable controls in place to manage utiliza­tion. We monitor these constantly and make changes.”

Yes, utilisation management will affect Pay-for-performance. Because Pay-for-performance programs have four essential elements that physicians should be aware of before participating. The first element is the set of performance measures being used. Performance measures fall into several categories: Utilization/cost management (e.g., average number of emergency department visits per patient per year),

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