THE FORMULARY, PHYSICIAN, AND PHARMACIST: MANAGING AND DELIVERING OUTPATIENT DRUG BENEFITS

Abstract

Pharmaceuticals are essential for the management of many chronic conditions. As a result, it is important to examine how the administration of pharmaceutical benefits affects physicians and pharmacists providing chronic care services. In the 1990s, HMOs and PPOs began to more aggressively manage outpatient pharmaceutical benefits, leading to the growth of pharmaceutical benefit management companies (PBMs).

In this exploratory study, 10 primary care physicians and 12 pharmacists in the San Francisco area were interviewed in 1999, and 11 more pharmacists in 2004, on how they worked with PBMs and their controls on prescribing and dispensing. Responses indicated major problems for both health professionals in negotiating with the PBM as a third party payor, in coping with switches and multiple formularies, and in added work for the health care professional. Increased risk to chronically ill patients for poorer outcomes is an important related problem with PBMs.

The Medicare drug benefit law passed in 2003 will likely result in similar problems for many beneficiaries, including those with chronic care needs. The paper proposes some policy solutions to reduce PBM problems for physicians, pharmacists and the Medicare population.

Citation

Penner, M., Penner, S.J. and Keck, W. (2004), "THE FORMULARY, PHYSICIAN, AND PHARMACIST: MANAGING AND DELIVERING OUTPATIENT DRUG BENEFITS", Jacobs Kronenfeld, J. (Ed.) Chronic Care, Health Care Systems and Services Integration (Research in the Sociology of Health Care, Vol. 22), Emerald Group Publishing Limited, Leeds, pp. 81-97. https://doi.org/10.1016/S0275-4959(04)22005-1