Abstract
Introduction
Pharmaceutical manufacturers must contend with the often-confl icting
requirements of three principal customer groups: payers, providers, and
patients. Health plans and pharmacy benefit management companies (PBMs)
maintain enormous infl uence over consumers' health care choices through their
control of formularies and reimbursement restrictions. However, formulary
designs are rapidly changing, and reimbursement restrictions are being used
more frequently. And although physicians remain the ultimate decision makers
regarding which medications patients receive, some traditional methods that
drug manufacturers have used to access physicians are becoming increasingly
difficult to employ. Meanwhile, the spread of "consumerism" has begun to shift
responsibility for health care to patients-who may not be willing to spend as
much money on drugs in a brave new world that features consumer-driven health
plans (CDHPs) and 24/7 access to health care information via the Internet.
Reconciling the demands of all three groups is likely to prove more difficult
for drug manufacturers in the future.
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- Cost-containment measures are proliferating within the reimbursement plans
of managed care organizations (MCOs) and PBMs. What are the most popular
cost-containment measures? Why might some costcontainment measures
backfire?
- Faced with growing numbers of drugs and increasing costs, the pharmacy and
therapeutics (P&T) committees that decide the composition of formularies for
MCOs and PBMs are becoming increasingly demanding of drug manufacturers.
What information are P&T committees specifi cally requesting from
manufacturers so that these committees can evaluate the overall value of
manufacturers' products?
- More than three-quarters of P&T committees regard drug acquisition costs
as the predominant factor in formulary and reimbursement decisions. However,
the vast majority of P&T committees are prepared to give preferred formulary
status to certain new drugs that are in fact more expensive than current
formulary drugs. Under what circumstances are P&T committees likely to
grant preferred status to more expensive drugs?
- Spending by pharmaceutical companies on physician detailing has recently
declined, which may refl ect growing resistance to this type of promotional
practice in the medical community. What barriers do manufacturers
increasingly have to overcome to maintain their detailing activities?
- In recent years, the role of "consumerism" in U.S. health care has
attracted considerable attention and introduced the creation of
consumer-driven health plans (CDHPs). Why might the spread of CDHPs be bad
news for drug manufacturers?
Scope
- Payers: new designs for MCO and PBM formularies; the use of rebates
and discounts; the proliferation of cost-containment measures.
- Providers: changes in the use of physician detailing, professional
advertising, and sampling.
- Patients: increased direct-to-consumer advertising; the rise of
"consumerism"; the establishment of health-savings accounts and CDHPs; the
infl uence of the Internet.
- Outlook and implications: the reimbursement environment; the
increasing role of generics; new criteria for formularies; the use of health
technology assessment and health economic evaluation; increasing consumer
emphasis on disease prevention and wellness programs; the role of CDHPs; the
infl uence of health-related Web sites.
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