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Exploring the Spectrum of Cardiovascular Care

This supplement is the first of two reports that are based on the 2004 Medical Director Colloquy, an interactive forum between top medical managers and an expert faculty comprising medical and business professionals. Managed care decision makers seek to address the performance gap that exists in translating recent treatment advances in cardiovascular disease to common practice in ambulatory settings. This supplement allows readers to benefit from the exchange of ideas that occurred at the 2004 Medical Director Colloquy, including an overview of unwarranted practice variation, emerging therapies in anticoagulation, and advances in treating systolic heart failure that are aimed at disrupting the neurohormonal cascade.

Highlights:

  • Quality of care and geographic variations in rates of health care utilization
  • Available anticoagulants and anticoagulant management services
  • Rationale behind warfarin clinics
  • Heart failure and why it is often misdiagnosed
  • Effective care, preference-sensitive care, and supply-sensitive care

Managing the Spectrum of Cardiovascular Care

This supplement is the second of two reports that derive from the 2004 Medical Director Colloquy, an interactive forum between top medical managers and an expert faculty comprising medical and business professionals. Decision makers in managed care have a range of concerns relative to cardiovascular disease management, from optimal treatment approaches to cost efficiency and integration of new technologies. This supplement invites readers to benefit from the exchange of ideas that took place at the 2004 Medical Director Colloquy, including an examination of best practices, from theory to implementation.

Highlights:

  • A disease management program for congestive heart failure
  • An effective ìpay for performanceî program
  • First-line therapy for the metabolic syndrome
  • Race as a crude predictor of clinical factors
  • The effects of genetic variation across human populations
  • Weight management strategies for children and adolescents

Treating Psoriasis as a T-Cell Mediated Disease

Outpatient treatment costs for psoriasis are estimated at $1.6 to $3.2 billion annually. In the commercial managed care population, psoriasis treatment consumes about $7 per member per year (PMPY), including prescription drugs and physician services.

The potential market for new biologic agents is significant. If all patients with moderate to severe disease were treated with a biologic agent, the potential cost would approach $5 billion annually, which translates to $15 PMPY for the entire managed care population.

Demonstrating the Value of Pharmaceuticals Across the Healthcare Continuum

At the 16th Annual Managed Healthcare Symposium, some of the most knowledgeable health care experts in the United States were invited to lecture, debate, and explore medical innovation and the role of pharmaceuticals in the delivery of high-quality care. This supplement is derived from those discussions, the topics of which include trends in healthcare consumerism, FDA movements to ensure safety, improvements in disease-state outcomes, increases in quality of life, and the economics associated with these complex subjects.

Highlights:

  • Assessing the Impact of Healthcare on the Consumer
  • FDA Update: Drug Costs, Regulatory Simplification, and Competitive Balance
  • Drug Importation and Consumer Demand
  • Are the Benefits of Newer Drugs Worth Their Cost?
  • Making the Switch: Prescription to Over the Counter
  • The Evidence-Based Formulary
  • Pharmaceutical Innovation, Emerging Technologies, and Consumer Demand
  • Successful Patient Compliance and Persistency Programs
  • Yankees' Skipper Triumphs Over Prostate Cancer

Diagnosing and Treating Depression in a Managed Care Environment: Concerns, Perceptions, and Misperceptions

Depression remains underdiagnosed, and even when it is diagnosed it is undertreated. Exploratory discussions with providers from managed care environments have yielded several perspectives that might help to explain the well-documented poor performance in the treatment of depression. This supplement, derived from the proceedings of the Economic Working Group's third advisory board, examines perceptions and misperceptions in the managed care marketplace and examines them in light of the published literature.

Highlights:

  • If so many patients currently are prescribed antidepressants, why is the disease still undertreated?
  • If so many people suffer from depression, why are physicians not diagnosing it?
  • Did patients who were noncompliant with antidepressant medications need the medications in the first place?
  • Aren't depression disease management programs extremely expensive?
  • Don't national guidelines stipulate discontinuation of antidepressant therapy at or before 6 months?
  • Does HEDIS play a big role in improving the care of patients with depression?

Reimportation of Pharmaceuticals: Economic and Policy Implications

This supplement explores the reasons for international price differences in drugs and examines the economic and quality ramifications of increased use of reimported pharmaceuticals. In addition, a panel of experts considers the characteristics of pharmaceuticals procured through nontraditional distribution channels. The perspectives of various stakeholder groups are presented. Based on a conference hosted by the University of Michigan Center for Medication Use, Policy, and Economics.

Highlights:

  • Differentials in International Pharmaceutical Expenditure
  • Overview From the National Association of Boards of Pharmacy
  • Economics and Risk of Reimported Pharmaceuticals
  • Vulnerable Points in the U.S. Drug-Distribution System
  • Reimportation and the Consumer
  • FDA Quality Assurance and Reimportation

The Importance of Blood Ketone Testing in Diabetes Management

The relative benefits of blood- and urine-ketone testing for assessing ketosis in diabetes patients are discussed, with a look at why the American Diabetes Association states that blood-ketone monitoring is preferred for diagnosing diabetic ketoacidosis in type 1 diabetes patients. For confirmation of ketosis and ketoacidosis in the home or the decentralized setting, health care professionals and patients with diabetes have had access to urine-ketone dipstick methods for more than 30 years. There are serious limitations to urine-ketone measurements, both in terms of accuracy and predictive value, however. The advent of the specific measurement of the major ketone in blood, beta-hydroxybutyrate, provided a new option.

With annual medical costs to treat patients with DKA in excess of $1 billion, the pharmacoeconomic implications of appropriate management of type 1 diabetes also are a central focus of the discussion.

Highlights

  • Detection of Ketosis and Monitoring of Diabetic Ketoacidosis
  • Novel Syndromes of Ketosis-Prone Diabetes: Implications for Management and Medical Economics
  • Role of Blood Ketone Testing in Sick-Day Management
  • Challenges and Opportunities in Diabetes Care: Improving Outcomes With Education, DM, and Technology
  • Roundtable Discussion: Evaluating Tools for Ketosis Assessment in Diabetes Patients

The Rationale for Early, Aggressive Treatment of Type 2 Diabetes: The Cost Ramifications of Improved Health Outcomes

This supplement is based on the proceedings of a diverse advisory group, including managed care medical and pharmacy directors, physicians, an employee benefit consultant, and an academician. The initial part of the discussion focuses on current treatment modalities and expected outcomes for type 2 diabetes, with an eye toward designing optimal treatment plans that can prevent disease or mitigate its progression. After the clinical topics, the supplement focuses on issues of disease management and the perspective of the payer.

Highlights:

  • Overview of the Pathology of Type 2 Diabetes
  • Treatment Modalities and Expected Outcomes for Patients
  • Costs Associated With the Disease
  • The Role of Modeling in Performing Economic Analyses
  • Cost-effective Treatment Measures
  • AMCP Format for Standardizing Formulary Submissions
  • Employerís Perspective on the Disease

P&T Digest: Depression

David V. Sheehan, MD, MBA, Chief Medical Editor

Depression is one of the most common illnesses in the United States and a major driver of health care utilization costs. Failure to diagnose and treat this condition can lead to poor yet avoidable medical and financial outcomes. The primary goals and challenges of treating depression involve accurate diagnosis of this highly comorbid condition and improving patient compliance with therapy.

This peer-reviewed publication is a digest of up-to-date guidelines for treatment, therapeutic approaches to treatment of depression, pharmacoeconomic considerations in treatment, and a discussion of comorbid conditions. It is a valuable tool for primary care physicians, mental health practitioners, pharmacists, and P&T committee members.

Highlights:

  • Depression: Underdiagnosed, Undertreated, Underappreciated
  • Prevalence and Economic Effects of Depression
  • Clinical Practice Guidelines for Treating Depression in Primary Care
  • An Overview of SSRI and SNRI Therapies for Depression
  • Pharmacoeconomic Evaluation of Antidepressant Therapies
  • Adherence With Antidepressant Medication
  • A Review of HEDIS Measures and Performance for Mental Disorders
  • Overview and Treatment of Social Anxiety Disorder

Innovation and Drug Reimportation: Cost, Value, and Tradeoffs — Economic, Legal, and Public Policy Implications

This supplement was generated from a unique forum that focused on the potential impact of pharmaceutical reimportation on medical innovation. The articles within will assist noneconomists in understanding why the pharmaceutical business sector relies more on the integrity of intellectual property and the ability to entice significant investments than do other business sectors.

Discussions on this topic have been heated and are particularly important, as drug costs continue to increase in the United States, and proposed solutions have the potential to be detrimental to the core of the pharmaceutical industry. The costs and benefits of drug reimportation are discussed and analyzed by the countryís top experts in these areas.

Highlights:

  • Legislation and Pharmaceutical Reimportation
  • Price Regulation and Innovation
  • Price Differentials Between Canada and the United States
  • Reimportation and the European Experience: What the United States Can Expect
  • Roundtable Discussion: Implications of Research for Public Policy

Effective Hypertension Management With New Treatment Paradigms

Despite the reports that have been released by the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure since 1977, increasing the percentage of Americans who know that they have hypertension and the numbers of those whose hypertension is being treated or controlled remains a tremendous challenge. Scores of drugs exist to treat hypertension ó on which Americans spend billions of dollars each year, but billions more go toward costs associated with stroke, heart attack, and kidney disease stemming from undetected or inadequately treated hypertension.

In this context, a distinguished panel convened to discuss the scope of this health care crisis and the steps to to be taken to at long last address it effectively. Their deliberations are contained in this supplement.

Highlights:

  • JNC-7 and the New Therapeutic Approaches
  • Role of Fixed-Dose Combination Therapy
  • Economic Impact of Poor Diagnosis and Management
  • Roundtable Discussion: Effective Diagnosis, Management, and Treatment
  • Roundtable Discussion: Minimizing Costs and Maximizing Outcomes in the Real-World Setting

Reversing Asthma-Related Morbidity and Mortality Through Patient Persistency

A panel of experts gathered to discuss challenges in asthma management, including disease variability, appropriateness of the National Asthma Education and Prevention Program guidelines, patient compliance, and accuracy of pharmacy claims data as a basis of severity classification.

The panelists discussed revising the asthma classification system and initiation of corresponding changes in treatment recommendations. Important studies were examined, highlighting compliance variations relative to pharmacotherapeutic options, the association between treatment and outcomes, the effect of nonreported short-acting beta2 agonist use on asthma classifications and outcomes data, and quality-of-life issues for different initial maintenance therapies. Also, the panel looked at methods of analyzing data on asthma management from individual health plans, outlining how other health plans can apply these insights.

Highlights:

  • Understanding Asthma Severity — Variability of Classifications and Outcomes
  • The Truth About SABA Pharmacy Claims — Results from a Prospective Study
  • Guidelines, Treatment Options, and Outcomes Data — a Health Planís Perspective
  • Roundtable Discussion: Challenges: Classification, Persistency, and Perceptions of Disease Control

The Future of Medicaid: What Will Medicaid Look Like in 2010?

Medicaid is the largest, and probably the most complex, health insurance program in the United States. As a federal-state partnership, Medicaid is buffeted by politics at both levels. State budget crises tend to affect it directly, with federal fiscal politics always lurking in the background. What can and should we expect of it? Five experts gathered at the University of the Sciences in Philadelphia in May 2004 to define challenges and craft a consensus on solutions, as summarized in this publication.

Highlights:

  • The Challenges Medicaid Faces: Funding and Its Role
  • We Ask a Lot of Medicaid but We Don't Fund It Accordingly
  • Realigning Medicaid Means Realigning Incentives
  • Primary Policy Considerations: Funding and Flexibility
  • An Optimistic Perspective: Medicaid as Cinderella
  • Roundtable Discussion: Where Do We Go From Here?