Can making tough decisions of that kind make a health plan unpopular with its members and with physicians?
Making difficult choices comes with the territory. If you are committed to the highest quality, cost-effective drug formulary with the goal to leverage effective alternatives to expensive drugs or to steer members away from medications that are not medically necessary, then your decisions will not always be universally popular.
For example, if your formulary philosophy is to manage ‘me-too’ drugs — new drugs that are introduced that are virtually the same in clinical quality as an established drug — then initially this can be perceived as a barrier. However, the reality is that this will eliminate waste, helping a health plan be a good steward of the limited resources available.
How are formulary decisions made?
There are different models that can be employed. At UPMC Health Plan, for instance, the decision on which drugs to include on the formulary is made by our Pharmacy and Therapeutics (P&T) Committee. Our P&T Committee consists of primary care physicians, specialists, and pharmacists from a variety of practice settings with expertise in many different therapeutic areas.
It’s important to staff the committee with professionals with different specialties and viewpoints, because the diversity of a P&T committee provides the proper foundation for an objective decision-making process. A P&T committee should make decisions based on the strength of published clinical evidence and clinical practice experience.
And as in all pharmacy decisions, the protection of the patient’s health and safety must be the primary goal.
What are some examples of how a formulary can be cost-effective?
Well, take the category of sleep aids. Drugs that are designed to help people sleep have become big business in recent years. With major advertising aimed at consumers and billions of dollars in sales, many patients believe that these aids will provide them with the latest cure for their sleeplessness. But, in many cases the new drug is no more effective than others already on the market. By keeping clinically equivalent, new sleep aids off a formulary, and by directing members to effective alternatives and generics, you can limit access to the new drug. As a consequence, you also hold down costs without sacrificing care quality.
Another example would be branded narcotics. In many cases, they offer little or no therapeutic value over commercially available generic alternatives, while also presenting a high potential for abuse. But because there are good cost-efficient alternatives available, you can keep high-cost branded narcotics off the formulary and save members money in reduced co-payments while potentially decreasing the risk of abuse.
Chronis Manolis is vice president of pharmacy services for UPMC Health Plan. Reach him at [email protected] or (412) 454-7642.