These examples demonstrate that focusing on care improvement as a primary goal can lead to both safer care and meaningful savings.
This is important to health plans for two key reasons: It shows how plans can accomplish the triple aim of health care reform as voiced by Donald Berwick, MD (“better care, better quality, lower cost”), and it also provides a basis for how plans and accountable care organizations will be able to align their goals to benefit stakeholders.
Coumadin is, of course, cheaper, and with the home self-testing INR devices, we have seen an improvement in compliance. My main concern is that there is no rapid antidote to these new drugs in cases of emergency, as there is with Coumadin and heparin.
Analysis takes time and often the circumstances cannot wait. The cost will be a definite drawback for the utilization of these newer agents.
The lack of consistency in formulary designs that use preferred and nonpreferred agents is perceived as arbitrary and unfair by patients and their advocates.
The National Multiple Sclerosis Society finds that it is not unusual for one health plan within a state to designate two MS drugs as preferred while at the same time another health plan within the same state gives the same two MS drugs the exact opposite designation. To this confusion can be added changes within the same formulary.
It is distressing to read letters from health plans to their enrollees telling them that the drug they have been taking for years is now being re-classified as “nonpreferred” and they now need to pay significantly more out of pocket if they want to remain on that drug.
Patients are being put into the position of paying more, or switching drugs, with no clinical reason provided. Until there is strong head-to-head evidence-based data comparing the MS drugs, such decisions are perceived as totally random and unrelated to individual patient response.
Federal Health Affairs and Insurance Policy
National MS Society