Management: Strategies for Providing Pharmacy Services in Managed Health Care Plans

MANAGEMENT

STRATEGIES FOR PROVIDING PHARMACY SERVICES IN MANAGED HEALTH CARE PLANS By Linda D. MacKeigan and Lon N. Larson

M

anaged health care may be defined as systems, programs, or actions aimed at controlling health care utilization and costs. 1 Although of recent origins, managed health care is a rapidly growing phenomenon manifested in such arrangements as health maintenance organizations (HMOs) and preferred provider organizations (PPOs). The concept is not limited to alternative delivery systems; managed care has also been adopted by indemnity insurance plans and corporate purchasers of health care. Pharmacy services are accepted as an integral part of most managed care systems. In 1985, 83% of prepaid plans surveyed by the Group Health Association of America offered pharmacy services; 73% contracted with outside pharmacies and 10% had in-house pharmacies.2 According to a Drug Topics survey conducted in December 1986, 40% of all pharmacies participate in an HMO program. 3 The minimal pharmacy service in a managed care system is the provision of the drug commodity in a manner consistent with prescription drug laws. Since all pharmacies can be expected to meet this requirement, participating pharmacies are selected in some cases on the bases of "low bids" and an adequate number of pharmacies for patient access to the service. From a broader viewpoint, pharmacy's responsibility extends beyond the drug to the entire drug-

use process. Pharmacy services can improve the quality of drug prescribing and use, thereby enhancing the cost-effectiveness of drug therapy by increasing effectiveness and decreasing adverse effects. Effective drug therapy may also reduce the need for other, more expensive, medical goods and services. Currently, most managed care plans are taking the narrow approach, emphasizing the price of the drug product when negotiating pharmacy contracts. 3 ,4 Several prominent plan administrators and health care consultants, however, are of the opinion that a focus on quality is evolving. 3 ,5 -8 Pharmacies may be able to facilitate this change in focus. One insurance administrator has stated that pharmacies need to take some initiative in determining the structure and nmctions of pharmacy benefit programs. 7 Similarly, a health care management consultant has suggested that pharmacies should attempt to win contracts based on attractive professional services as well as price;9 these services represent a potential opportunity for a managed care plan to gain an advantage over competitors. Several aspects of managed pharmaceutical care undertaken by a pharmacy to improve the quality of care and to control health care resource utilization have not been extensively addressed. This paper discusses four of these subject areas: clinical services, cooperative ar-

American Phannacy, Vol. NS28, No. 4, April 1988/261

rangements for the provision of services, the formulary system, and quality assurance (including druguse review). Strategies related to each area are described and their effectiveness supported with evidence from the literature. Where possible, this evidence is cited from ambulatory care settings; however, in some cases, only information from institutions is available. Not discussed here are those measures designed to control costs through improved efficiency - inventory controls, purchasing practices, drug product selection, or computerized information systems. Such efficiency measures, long a concern to pharmacists in their efforts to maximize profits in the traditional fee-for-service system, have \ been covered in the literature. One caveat is in order. Many of the activities described are aimed at altering behavior. Consequently, each will meet with different acceptance and varying degrees of success in different settings. Therefore, managed pharmaceutical care should be tailored to the needs and corporate culture of each health care plan.

I

CLINICAL SERVICES Christensen has suggested that drug-related services in an organized health plan should have an underlying rationale.lO He proposed that some specific group of providers must be responsible for • Ensuring that the most appro49

I MANAGEMENT priate drug- is prescribed for the patient; • Providing drug services to process the prescription order accurately and efficiently; • Ensuring that patients adequately understand how to consume each prescription medication; • Ensuring that patients actually consume the medication as directed. Brodie was the first to formalize the now commonly accepted proposition that pharmacists should assume this responsibility.l1 Several clinical pharmacy services would help pharmacists meet this objective: consultation to the primary care provider, prescriber education, drug therapy monitoring, . patient education, and home health care.

Consultation to the Primary Care Provider In institutions, pharmacokinetic and parenteral nutrition consulta/ tion by the pharmacist has resulted in less expensive regimens, increased the effectiveness of therapy, and decreased adverse effect. 12-1~· Pharmacokinetic services are becoming increasingly feasible in the ambulatory care setting as the complex technology of serum drug assays is simplified. A serum drug assay service run by pharmacists in an outpatient clinic has been shown to be self-supporting. 16 ,17 Similarly, the economic feasibility of a blood level service in a community pharmacy has been demonstrated. 18 A pharmacist has even established a private practice in clinical pharmacokinetics consulting. 17 .

Prescriber Education Suggested group education programs for communicating information to prescribers on appropriate drug use include in-service education meetings, grand rounds presentations, newsletters, and memos. Drug education programs provided by clinical pharmacists to medical residents have improved prescribing and resulted in improved quality of care and cost savings to an 50

institution. 19,2o Evidence ,is mix~d on the effect of printed drug information materials, when used alone, on c~angirig drug prescribing behaVIor. 2I-24 . A survey of 100 ·HMOs published in 1984 found that about half the plans distributed bulletins and pharniacy newsletters and that 41 % of HMO pharmacies offered / inservice training at group medical meetings. 5 Another method of educating physicians 'about drugs is counter-

education rather than restriction of formularies is preferable for drugs that are quite safe and effective but that are often used far in excess of their specific indications. 21 A target drug program is the continuing education approach to reducing inappropriate use of expensive therapeutic equivalents. Target drug programs are an alternative to the deletion or restriction of for- ' mulary drugs and may therefore be more attractive to physicians. These programs are an extension of the counterdetailing concept. Each time a targeted drug is prescribed, a pharmacist consults . with the physician to,determine if criteria for its use are met. If the pharmacist considers the use inappropriate, t~e pharmacist informs the physician of appropriate use, costs, and alternative agents. The final drug choice is left to the physician. 25 Several studies have documented the cost-effectiveness of target drug programs in hospitals. 26-28 Another study, compared the impact of two intervention methods on physician detailing, which is similar to the prescribing of parenteral cephaloeducational activities of pharsporins. Publication of a pharmacy maceutical company "detailers" but newsletter produced a minimal efhas the purpose of countering defect, whereas the newsletter plus tailers' effects on physicians. Educapersonal interaction between phartion is conducted in one-on-one enmacists and physicians resulted in counters between pharmacist or significant cost savings. 29 physician educators and prescribA target drug program for ers. Data on clinical pharmacology . nonsteroidal anti-inflammatory and cost issues are used to alter drugs (NSAIDs) in a primary care physicians' prescribing decisions. clinic of a group model HMO was One pharmaceutical executive of a less successful. 3t> Pharmacists were major HMO chain envisages coununable to redqce the costs asterdetailing as the preeminent new . sociated with NSAIDs but did have role for pharmacists in managed a modest effect in altering salicycare plans. 8 late prescribing patterns. However, In a recent study in which pharthere wer~ several possible explanamacists functioned as countertions for the lack of a significant detailers, two visits to physicians program effect, the most compelling within a 6-month period resulted in of which was the existence of a relasavings in drug expenditures for tively strong drug-use control proMedicaid patients substantially gram (eg, drug formulary controls) greater than the costs of the counbefore the target drug program was terdetailing program. Additional implemented. nonquantified benefits, such as imDrug Therapy Monitoring proved quality of care, would have augmented the cost-benefit - still Drug therapy monitoring refurther. The authors believe that quires assimilation of patient data I

American Pharmacy, Vol. NS28, No.4, April 1988/262

MANAGEMENT and continuing assessment of the for both prospective and concurrent Patient Education therapeutic effectiveness and/or admonitoring. _verse effects of drug therapy in a The purpose of drug ,monitoring Estimates are that at least 30% particular patient. 31 The most comis only ,partially fulfilled when poof patients fail to comply with the monly used type of patient data is tential problems in drug therapy medication instructions of the the patient medication profile. It, physician. 36 Patient counseling are detected. Problem identification can be used to identify potential must be followed by problem resolustrategies to increase compliance drug-drug interactions or adverse tion through intervention with the are more extensive than just providdrug reactions, probable over- or ing the patient with information on patient, physician" nurse, or other health care professional. under-utilization of a drug, and medication use. They include emphasizing the importance of -the A study conducted by the Group seemingly irrational drug regitherapeutic plan; taking steps to reHealth Cooperative of Puget Sound mens. One HMO chain insists that duce the cost, complexity, duration, has documented the feasibility and contracting pharmacies have computerized patient profiles. 32 and amount of behavioral change contribution of drug therapy required by the regimen; increasing Other sources of drug monitoring the convenience of the regimen by information include the patient and tailoring it to the person's life-style; family members (for information on modifying perceptions likely to inboth past and present therapy), hibit compliance; and providing physical assessments such as blood continuity of care. 37 Proper counselpressure and pulse, and if available, ing is potentially a complex and laboratory data. Such additional intime-consuming activity. formation is particularly important either Renewal reminders in assessing the efficacy of current through mailed postcards or teledrug therapy, a process called conphone calls are one means of current drug monitoring. The facilitating continuity of care. Both monthly drug regimen review conmanual and computer systems to ducted by consultant pharmacists monitoring by pharmacists in the determine renewal frequency for busy (pharmacist productivity rate in nursing homes is an example of chronic medications have been deof 20 prescription orders processed concurrent drug monitoring. veloped. A computer-identified teleper hour) in-house pharmacies of a In a community practice, where phone renewal reminder system in large HMO.33 Pharmacists detected patient information is difficult to aca community pharmacy has been quire, pharmacists tend to emfrom two to four problems per 100 shown to be effective in promoting prescription products dispensed. phasize prospective monitoring timely prescription renewals. 38 ,Approximately 80% res-ulted in that is, the detection of potelJ.~:al Pharmacist interventions on bedrug problems such as dispensing , some form of problem resolution half of compliance are cost-effective either the gathering of additional a drug to which the patient is allerwith respect to total health care information or intervention. In 9% gic or that interacts with another costS. 38 This fact appears to have of all problem interventions the outdrug in the patient's regimen. Opbeen recognized by the -HMOs, income was a change in the prescriptimization of drug therapy, however, surance firms, and co~orations surrequires concurrent monitoring, tion order. The average amount of veyed by Drug Topics; they ranked pharmacist time per problem interusing various data sources, in order vention varied from 6.0 to 7.8 min- , patient counseling in the group of to determine that the most appromost preferred drug program feautes across problem types. priate drug, dosage regimen, and tures. Several felt, however that '!\vo other case studies illustrate route of administration have been pharmacists were not providing used. the value of drug monitoring. In enough patient counseling 'to plan one, the cost-effectiveness of a clinComputer technology has greatly enrollees. In the view of APhA's ical pharmacy program that infacilitated the maintenance of Committee on Third Party Promedication profiles 'and can assist cluded drug , monitoring was regrams, the pharmacist is often ported in a staff model HMO. 34 In in the process of drug monitoring placed in the difficult position of the second, the addition of a pharas well. A commonly used computer being expected to provide profesapplication for drug monitoring is macist to an internal medicine sional services such as patient counone that detects potential drug inclinic's staff was accompanied by a seling while receiving inadequate drop _in the average cost of medicateractions, a form of prospective reimbursement from third partion per patient visit. 35 This was drug monitoring. Some hospital ties. 39 This view is corroborated by attributed to the ability of the pharpharmacies have computer systems a major consumer group that perthat provide patient laboratory macist to affect prescribing pracceives HMOs as being highly vari- , data. This information is valuable tices. American Pharmacy, Vol. NS28, No.4, April 1988/263

51

MANAGEMENT

able in meeting patient infonnation needs:40 Thus, a patient counseling service may represent a value-added service that phannacies can provide managed health care plans; however, it may require careful negotiation between phannacies and plans over reimbursement policies. Outreach programs and patient. education services are viewed by Curtiss as the two most important opportunitIes for phannacists in a prepaid health plan. 41 Outreach programs are designed to prevent hospital admissions and reduce ambulatory care visits through educating subscribers regarding the importance of healthy life-styles, the avoidance of certain undesirable health behaviors, and better selfcare. The drug-related component of these programs can include: drug-use education, drug-use screening and evaluation, and dosage adjustment and direct intervention .in certain patients on maintenanced medication therapies. Studies have shown that phannacists and interdisciplinary health care teams have been successful in patient education programs regarding more effective self-care. 41

I

cally in an effort to contain the costs of hospitalization. 44 HHC services are the mo~t common revenue-producing services offered by hospital phannacies. 45 Cost-effective home care programs for drug .therapy have been developed by hospital phannacies for the parenteral administration of nutrition, antibiotics, cance~ chemotherapy, and other drugs. 46 HHC services are also provided by community phannacies an.d by in-house HMO pharmacies. 43,47

THE FORMULARY SYSTEM The Formulary

Greater continuity of phannaceutical care results when the phannacy providing phannaceutical services to a health care plan also provides home health care.

Home Health Care Services

COOPERATIVE PHARMACY SERVICES

Home health care (HHC) has been defined as health-related products or services that are made available to a patient at home to avoid or minimize institutional care. 42 Six categories of services have been identified for a comprehensive pharmacy-based home care program: durable medical equipment, respiratory equipment, infusion therapy, apnea monitoring, phototherapy, and phannaceuticals (home dia~­ nostics and prescription drugs). 3 All require specially trained clinicians. The components of a phannaceutical HHC program are patient screening and. selection, education of patients and families, compounding of products, supply distribution, and clinical management. 42 The HHC segment of the health care industry is growing dramati-

In selecting provider pharmacies, organized health plans seek an adequate number of conveniently located pharmacies to meet the needs of their enrollees for accessible phannacy services. The number and location should be sufficient to ensure that significant transportation barriers to care are not created. A prescription delivery service or prescription mail service is an important plan feature for patients who have mobility or transportation problems. Finally, there should be some arrangement for phannacy services in emergencies that occur after nonnal business hours. Phannacy chains or networks are more likely to be able to meet the accessibility needs of the plan than a collection of independent pharmacies. They are also more likely

52

to have the resources to provide programs such as drug utilization review and quality assurance. For the health plan, negotiations and contracting are simplified when dealing with an organized group that represents many pharmacies. 3 From the individual pharmacy's viewpoint, efficiencies and market power are gained. 48 ,49 The growing number of pharmacy services administration organizations (PSAOs) and PPOs is a response to the needs of managed care plans. According to the 1986 Drug Topics, 35% of community pharmacies belong to a PSAO. 3

The fonnulary system is a method whereby the medical staff of a health-care organization, through a phannacy and therapeu. tics (P&T) committee, evaluates, appraises, and selects from among numerous available medicinal agents and dosage fonns those that are considered most useful in patient care. 50 The fonnulary thus 'is a continually changing compilation of pharmaceuticals reflecting the current clinical judgment of the medical staff. 50 The fonnulary is considered to be the foundation of any system to contain drug costS. 25 Fonnularies, by limiting both the number of approved drugs and by restricting the number of brands of a drug, can .minimize drug and inventory carrying costs in the pharmacy. In addition, fonnularies can assist in changing prescribing patterns and can serve as educational tools. The presence or absence of a drug on a fonnulary is a statement of the appropriateness of the drug's use in that organization. 51 Fonnularies, however, are highly variable: they may list an extensive number of products (open fonnulary) or only a limited number (restricted fonnulary). Controls regarding nonfonnulary drug use may be strict or virtually nonexistent. It is not surprising then that

American Pharmacy, Vol. NS28, No.4, April 1988/264

MANAGEMENT the 1969 Health, Education, and Welfare Task Force on Prescription Drugs found that the existence of a fonnulary did not guarantee highquality medical care. 51 Similarly, a study of 52 randomly selected formularies from large-size hospitals suggested that major revisions were needed to maximize the effectiveness of their formularies. 52 , Although formularies have become a standard of practice in hospitals, studies of their economic and educational effectiveness are lacking. 53 Several studies conducted on the impact of formularies in , Medicaid programs have indicated no effect or a ne~ative effect on health care costs. 4-57 In spite of these findings, 19 states in 1985 used a formulary in their Medicaid _ program. 58 Formularies are fairly prevalent in organized health plans. A 1985 survey of innovative HMOs found that 70% had formularies. 5 The group practice model with an inhouse pharmacy particularly lends itself to a formulary system; however, formularies are used in other models as well. One HMO's formulary system uses a decentralized pharmacy distribution system incorporating the services of more than 60 independent pharmacies. 59 In this case, drug utilization is controlled through a closed, monthly peer review by the P&T committee of three physicians and three pharmacists. Pharmacists have a dual role in the formulary system. As members of the P&T committee, with the responsibility for providing informa,tion concerning the costs and therapeutic and adverse effects of drugs, they are instrumental in policy-making. They also have a role in facilitating adherence to the formulary. In one hospital, formulary adherence was improved when pharmacists intervened with pre,scribers of nonformulary drugs to suggest formulary alternatives. 60

Prescribing Restrictions A concept associated with that of

a restricted formulary is the use of prescribing restrictions for certain expensive drugs; for example, limiting the use of a drug to a particular medical or surgical subspecialty or requiring prior authorization before a drug can be ordered. The use of prescribing restrictions is based on the belief that they promote more careful consideration of the need for the restricted drug, The drawbacks are the time delay in initiating therapy while necessary authorizations are obtained and the

Pharmaceutical home health care- patient screening and'" selection, education of "patients and families, compounding of products, supply distribution, and clinical management - can produce revenues for the pharmacy and contain the costs of hospitalization. increased costs associated with the consultations that may be required. A 1985 national survey of shortterm hospitals indicated that 25% of these hospitals now have prescribing restrictions. 45 Several controlled studies have demonstrated significant reductions in costs and quantities of restricted antibiotics in hospitals following required consultations with an infectious disease specialist. 22 Education must accompany the restriction policy. Physicians not knowing why a drug is being restricted will probably continue to misuse it.25

Therapeutic Interchange Therapeutic interchange is a feature of the formulary system that allows the interchange by the pharmacist of drug products that, although not chemically identical, are deemed by the P&T committee

American Pharmacy, Vol. NS28, No.4, April 1988/265

to be therapeutically equivalent. Therapeutic interchange can involve either (1) pharmaceutical alternates - drug products containing the same therapeutic moiety, but differing in dosage form; or (2) therapeutic alternates - drug products containing different therapeutic moieties but of the same pharmacologic and/or therapeutic class and can be expected to have similar therapeutic effects when administered to patients in therapeutically equivalent dosages. 61 Pharmaceutical alternates and therapeutic alternates should be distinguished from chemical equivalents that are multiple-source drug products containing essentially identical amounts of the identical active ingredients, in identical dosage forms, and that meet existing physical-chemical standards in the official compendium. 61 Generic product selection is practiced with chemical equivalents. In a recent survey of innovative HMOs conducted for the Pharmaceutical Manufacturers Association (PMA), 7 of 20 HMOs had a "therapeutic equivalent" program. 5 The use of therapeutic interchange in managed health care is expected to grow. 8 In May 1987, the state of Kansas adopted "therapeutic substitution" as part of its Medicaid program. 62 Selection of another drug is not automatic, however; pharmacists must contact physicians to change prescriptions orders to the authorized drug in three drug categories - oral cephalosporins, nitroglycerin patches" and H2 antagonists. According to data from the National Pharmaceutical Council based on the practices of 57 HMOs, drug categories commonly earmarked for therapeutic interchange include: oral cephalosporins (79%), oral vitamins (54%), topical antifungals (53%), other antibiotics (43%), antihistamines (41%), antacids (35%), NSAIDs (31%), and laxatives (20%).63 Some question the legality of therapeutic interchange in a com53

MANAGEMENT munity pharmacy setting. In hospitals, where the practice is fairly common, the legal basis lies in the contract between the prescriber and the institution, by which the prescriber consents to the hospital formulary system and its attendant rules and regulations. 64 A few states have explicit regulations regarding therapeutic interchange (eg, Wisconsin limits it to hospitals and nursing homes).65 In others, however, where it is not mentioned in state practice acts and regulations, significant legal questions exist.

QUALITY ASSURANCE Quality assurance (QA) is the means by which the characteristics of a service or product are maintained within established standards of quality. A quality assurance program is "a formal, structured program of monitoring, evaluating, and correcting activities for the purpose of verifying and documentin~ satisfactory completion of work." 61t consists of the following components: • A beginning definition of what constitutes acceptable service (or product) done in the format of written criteria and standards; • An assessment phase using the written standards to determine whether or not the services and products meet the definition of acceptability; • An educational-correctional phase designed to eliminate the specific performance or product deficiencies uncovered in the assessment phase; • A subsequent reassessment to determine if the educational-correctional actions have been successful' • Periodic review of the set of quaiity standards to see if they require deletion or modification. 61 A QA program is more likely to be successful if in its planning stages input is provided by those whose performance is to be reviewed and if the program is continuous rather than periodic. 68 The most commonly used 54

taxonomy of methods of health-care quality assessment, as developed by Donabedian, recommends basing the evaluation process on structure, process, and outcome criteria. 69-71 Structure is defined as the tools, resources, and relatively stable characteristics of the providers of care including the organization. Process is the set of activities of both technical and interpersonal natures that occur between the health-care provider and the patient. Outcome is a change in a patient's current and future health status that can be attributed to antecedent health care.71 Assessment of quality can proceed in any combination of these three general directions. One model quality assurance program divides QA into two separate activities: audit of programs controlled only by the pharmacy (eg, drug distribution and control), and audits of areas that are the joint responsibility of the medical staff and the pharmacy (eg, drug utilization review). 71 The same approach will be taken in this document.

Quality Assurance Programs for Pharmacy Services Any activity, service, or product supplied by a pharmacy to fulfill its contractual obligation to the organized health plan can be selected for a quality assurance program. Ideally, all required services would be audited; however, this may not be practical. It is therefore best to select services or areas based on identification of important or potential problems, or related concerns in the provision of pharmacy services. 7o QA programs for pharmacy services may be conducted by either the plan or by the pharmacy. Activities or services that the plan may wish to have assessed are prescription dispensing, drug monitoring, formulary control, and patient counseling. QA criteria in these areas might include the accuracy of prescription orders dispensed, mean waiting time for prescription dispensing, completeness of medication profiles, the prevalence of "inappropriate" prescription orders, and patient knowledge of how to ad-

Pharmacy Strategies and Targets for Managed Health Care ,Strategy

Target

Clinical Services» consultation .'..... .. . physi~ian prescriber education group programs .. . ... . ....' ..... .... . ..... . . . . .... . . ....... . . . . . . . ...... . . physician counterdetailing . .. . ... . .... .. .... . . . . . ... . ....... .. .... . ... ... ....... .... physki.an target drug programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . physician drug monitoring . .. .. . .. .. . , .. '.. . . ..... . .. .. .. .. . .. . .. .. . .. . .. .. .. ... . physician patient education medication counseling ....... .. . . . .. ...... ... .. . . ....... .... .. . .. .. .. . ...... enrollee outreach programs ....... . . . ....... . : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . enrollee home care seNices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. enrollee Cooperative Arrangements for the Provision of Pharmacy Services delivery or mailseNice ..... . ........... ... .............. ... .... . .. ...... ... ...... plan emergency seNice .. .. .. .. . .. ..... . . . .... ..... . ........... ........ ......... : . ... plan number, location of pharmacies ..... ... .. .... .. / . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . plan The Formulary System the formulary '....... " ............... .. ........... ..... ~ .... . ...... . .. '... . " . phy;idan prescribing restrictions ... ... .. . . ... . .. .......................... ...... . .. .. .. physician therapeutic interchange .. .. . .. . " . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . physician Quality Assurance pharmacy seNices ... : .... . .. .. . ... . ...... . . .... . ...................... ... ... pharmacy OUR .......... . .. . ..... . . .... .. ... . ........ . . .. .... . .. ... . . ....... . ..... . physician

American Pharmacy, Vol. NS28, No.4, April 1988/266

MANAGEMENT minister their prescription medication.

Drug Utilization Reviews Brodie and Smith have defined drug utilization reviews (DUR) as "an authorized, structured, and continuing program that reviews, analyzes, and interprets patterns (rates and costs) of drug usage in a given health care delivery system against predetermined standards."68 Additional components include corrective action for performance that does not meet specified standards and subsequent assessment of the effectiveness of the corrective action. 72 The overall purpose of DUR as stated by the 1969 Health, Education and Welfare Task Force on Prescription Drugs is, first, "rational prescribing and the consequent improvement in the quality of care, and second, ... minimizing needless expenditures.,,73 The Joint Commission on Accreditation of Healthcare Organizations requires that DUR be conducted under the auspices of the medical staff with the cooperation of the pharmacist. 73 Thus, DUR is most often the responsibility of the P&T committee. This approach also makes sense in managed care. Programmatically, DUR should incorporate the five steps of a quality assurance process as outlined above. Areas of attention forDUR programs may include (1) necessity of prescribing; (2) appropriateness of treatment, including appropriateness of dose, route of administration, and drug of choice; (3) alternate therapies; and (4) individual physician prescribing patterns. 74 DUR may use retrospective, concurrent, or prospective methods for data collection, the retrospective approach being the most common. Stolar has explicated the differences among these methodologies. 67,75 Prospective DUR systems incorporate review of the drug order, using explicit criteria, before it is entered into the dispensing process. Prospective DUR is inherently the

most logical and effective type ofreview since substandard care can be eliminated before it is initiated. Concurrent DUR takes place while a patient is receiving a drug. Corrective action in prospective and concurrent review is timely and is directed at immediately changing the behavior of the individuals responsible for specific actions (or lack of action). Retrospectivereview is conducted after the course of therapy has concluded. Because it can be ac-

In the formulary system, pharmacists have adual role - prpviding information on drug costs and therapeutic and adverse effects, and improving adherence to the formulary. complished without disrupting the daily work patterns of physicians, retrospective DUR is the most feasible, adaptable, and thus popular DUR methodology. Corrective action in retrospective review stresses the need for a behavioral change in the future. Educational programs to effect the behavioral change are usually directed at groups of providers rather than individuals. Although there are several similarities between DUR and drug therapy monitoring, there is also an important distinction: DUR considers patterns of drug usage; drug therapy monitoring is oriented toward individual patients and their therapy. 73 In the 'Drug Topics survey, HMOs ranked DUR first among the desirable features of a drug benefit program. 6 More than half the HMOs in the 1985 PMA survey conducted some type of DUR, although none claimed to have a "fully satisfactory" DUR system in place. 5 ' Most programs in the PMA survey began by studying the overall

Atnerican Pharmacy, Vol. NS28, No.4, April 1988/267

number of prescription orders per member month and average cost per order. This approach enables the HMO to identify high utilizers and prescribers. In order, however, for DUR to have optimal impact on prescribing behavior, the physician must be provided with more detailed feedback on his or her use of drugs. Thus, it is important that reviews be conducted which target specific drugs or drugs used to treat specific diseases. Such reviews provide the best opportunity for pharmacist input. Pharmacists can participate in DURs in a variety of ways. They may be involved in the selection of drugs for review, in establishing criteria and standards for appropriate drug use, in data collection, or in educational programs for prescribers.

CONCLUSION Strategies for pharmacists who are or wish to become participants in the drug program of an organized health plan have been reviewed. 'These strategies, which pertain to the structure and functions of a pharmacy service deli very system, are listed in the accompanying table along with their respective targets. Collectively, their purpose is to improve the quality of care and contain ,costs through controlling utilization. Pharmacists may select from these strategies those that, in their judgment, are needed, feasible to implement, and likely to be effective for a particular plan. References to this article that pertain to the effectiveness of specific pharmacy strategies may be used in pharmacies to gain the support of plan administrators for the provision of these services. ®

REFERENCES 1. Anon., Project TIM.E., The Upjohn Co., Kalamazoo, MI, 1987, tab 87102. 2. Anon., Drug Topics, 131, 48, August 3,1985. 3. M. Glaser and V. Cardinale, Drug Topics, 131, 32, April 20, 1987. 4. Anon., Drug Topics, 131, 13, February 2, 1987.

55

MANAGEMENT 5. A Zuvekis et al., HMO Outpatient Pharmacy Trends, Pharmaceutical Manufacturers Association, Washington, DC, 1986. 6. V. Cardinale and M. Glaser, Drug Topics, 131, 52, May 4, 1987. 7. B. Weiss, Drug Topics, 131, 54, June 1,1987. 8. Anon., American Druggist, 195, 30, January 1987. 9. Anon., American Druggist, 195, 66, May 1987. 10. D.B. Christensen, in Handbook of Institutional Pharmacy Practice, M.C. Smith and T.R Brown, eds., Williams & Wilkins, Baltimore, MD, 1979, p. 555. 11. D.C. Brodie, Drug Intell Clin Pharm, 1, 63 (1967). 12. J.L. Bootman et al., J Pharm Sci, 68, 267 (1979). 13. J.R. Horn et al., Drug Intell Clin Pharm, 19, 45 (1985). 14. K.D. Mutchie et al., Am J Hosp Pharm, 36, 785 (1979). 15. J.E. Dice et al., Am J Hosp Pharm, 38, 1487 (1981). 16. J.D. Robinson, Am J Hosp Pharm, 38, 1713 (1981). 17. J.D. Robinson et al., Am J Hosp Pharm,41, 2048 (1984). 18. T.R Einarson, et al., Am Pharm, NS28, 76 (1988). 19. T.H. Self et al., Drug Intell Clin Pharm, 19, 749 (1985). 20. T.H. Self et al., Drug Intell Clin Pharm, 18, 241 (1984). 21. J . Avorn andS.B. Soumerai;NEngl J Med, 308, 1457 (1983). 22. S.B. Soumerai and J . Avorn, Milbank Memorial Fund Quart, 62, 447 (1984). 23. W. Schaffner et al., J Am Med Assoc, 250, 1728 (1983). 24. K.J. Fendler et al., Drug Intell Clin Pharm, 18, 627 (1984). 25. pw. Abramowitz, Am J Hosp Pharm, 41, 503 (1984). 26. pw. Abramowitz et al., Am J Hosp Pharm, 39, 1176 (1982). 27. pw. Abramowitz et al., Hosp Pharm, 18, 416 (1983). 28. N.T. Suzuki and L.D. Pelham, Am J Hosp Pharm, 40, 1187 (1983). 29. M.C. Lawlor and RL. Lucarotti, Hosp Formulary, 18, 402 (1983). 30. A Stergachis et al., Am J Hosp Pharm, 44, 525 (1987). 31. RB. Stewart, in The Practice of Pharmacy: Institutional and Ambulatory Pharmaceutical Services, D.C. McLeod and W.A Miller, eds., Harvey Whitney Books, Cincin56

nati, OH, 1981, p. 70. 32. J . Chi, Drug Topics, 131, 52, January 5,1987. 33. D.B. Christensen et al., Med Care, 19, 104 (1981). 34. C.R Fortner et al., Group Health J, 4,3(1985). 35. J.O. Covinsky et al., Drug Intell Clin Pharm, 14, 267 (1980). 36. D.L. Smith, in ThePracticeofPharmacy: Institutional and Ambulatory Pharmaceutical Services, D.C. McLeod andW.A Miller, eds., Harvey Whitney Books, Cincinnati, OH, 1981, p. 45. 37. M.H. Becker and LA Maiman, J Community Health, 6, 113 (1980). 38. D. Murphy, Am Pharm, NS25, 19 (1985). 39. American Pharmaceutical Association, AmPharm, NS26, 305 (1986). 40. B. Robinson, Drug Topics, 132, 14, January 18,1988. 41. F.R. Curtiss, Am J Hosp Pharm, 41, 721 (1984). 42. J.C. McAllister,AmJ HospPharm, 42, 2533 (1985). 43. AV. Rozzi, Am Pharm, NS27, 429 (1987). 44. Anon., Am JHospPharm, 44, 1522 (1987). 45. M.H. Stolar,AmJ HospPharm,42, 2667 (1985). 46. W.L. Harris Jr. and PJ. Mellott, Am J Hosp Pharm, 43, 699 (1986). 47. B. Robinson, Drug Topics, 128, 48, June 4, 1984. 48. S.w. Schondelmeyer, Am Pharm, NS26, 44 (1986). 49. B. Robinson, Drug Topics, 129, 36, May 20, 1985. 50. American Society of Hospital Pharmacists, Am J Hosp Pharm, 40, 1384 (1983). 51. M.J. Roberts and M.R. Summerfield, Hosp Formulary, 21, 481 (1986). 52. AP Lemay et al., Am J Hosp Pharm, 38, 506 (1981). 53. JA Green, Am J Hosp Pharm, 43, 2830 (1986). 54. D.L. Hefner, Cost-effectiveness of a Restrictive Drug Formulary: Louisiana vs. Texas, National Pharmaceutical Council, Washington, DC, May 1, 1980. 55. M.C. Smith and S. Simmons, in Proceedings of a Workshop at the Project HOPE Center for Health Information, Project HOPE, Millwood, VA, 1982. 56. D.M. Smith and PL. McKercher, Hosp Formulary, 19, 366 (1984).

57. B.S. Bloom and J. Jacobs, Med Care, 23, 872 (1985). 58. National Pharmaceutical Council, Pharmaceutical Benefits Under State Medical Assistance Programs, NPC, Reston, VA, 1987. 59. W.D. Hardigan et al., Contemp Pharm Pract, 3, 23 (1980). 60. L.A Packer et al., Am J Hosp Pharm, 43, 1461 (1986). 61. T.R. Covington, Drug Intell Clin Pharm, 17, 660 (1983). 62. J. Chi, Drug Topics, 131,46, July 6, 1987. 63. Anon., Am Druggist, 196, 36, September 1987. 64. J.L. Fink, Hosp Pharm, 18, 594 (1983). 65. M. Glaser, Drug Topics, 131, 47,July 6,1987. 66. D.P Soares, Am J Hosp Pharm, 42, 610 (1985). 67. M.H. Stolar,AmJ HospPharm,34, 139 (1977). 68. D.C. Brodie et al., J Am PharmaceuticalAssoc, NS17, 617 (1977). 69. C.E. Hynniman, in Handbook ofInstitutional Pharmacy Practice, 2d ed., T.R Brown and M.C.
Linda D. MacKeigan is a graduate student and Lon N. Larson, PhD, is assistant professor, Department ofPhp,rmacy Practice, College of Pharmacy, University of Arizona, Tucson, AZ. This paper was adapted from a poster session presented at the 134thAPhA Annual Meeting in Chicago in March 1987.

American Pharmacy, Vol. NS28, No.4, April 1988/268