US Managed Care Research Articles

A Guideline for the Use of Pharmacoeconomic Models of Diabetes Treatment in the US Managed-Care Environment

The Academy of Managed Care Pharmacy has recently created guidelines for the submission of pharmacoeconomic models. Although these guidelines provide a general framework for the integration of pharmacoeconomic models in the drug selection process, a more disease-specific and practical 'hands-on' approach is needed for pharmacy staff and Pharmacy and Therapeutics (P&T) committee members. To answer the question, 'How can pharmacoeconomic models comparing treatments for diabetes and its complications be evaluated and used to make more informed formulary decisions?' We determined the information needs of a managed care organisation (MCO) making coverage decisions for diabetes therapies and reviewed current guidelines for the submission of pharmacoeconomic models to MCOs. We then developed a set of practical questions for evaluating models of diabetes treatment in a managed-care environment. Information needed by P&T committees in relation to new diabetes medications includes the long-term benefits of reduced micro- and macrovascular complications and changes in drug utilisation patterns, in addition to the immediate drug budget impact. Because diabetes is a complex disease, the peer-review process should be relied on as a first step to help ensure the validity of a model. Then, the end-user of a model should evaluate the sources of data to inform the model,the generalisability of the model for an MCO population, andthe face validity of the assumptions of the model. Pharmacoeconomic models in diabetes offer potential for assisting P&T committee members in making more informed decisions. The guidelines presented here provide a practical approach for model assessment. However, additional expertise will be needed by MCOs to appropriately evaluate these models, and joint educational programmes between managed care, academia, and industry should be considered as a mechanism for improving technology assessment in diabetes care.

The Drama of Dysfunction: Value Conflict in US Managed Care

The transformation of the American health care environment from retrospective fee-for-service to managed care has been both rapid and chaotic. This period of change has been infected by value conflict, evoking unconscious processes in system participants as they have attempted to cope with personally threatening situations. This article attempts to elucidate this process by presenting an account of events and accompanying value conflict as it occurred over time. It also includes a systems analysis of the rapidly changing mosaic of unconscious processes that resulted from the divergent values held by the public and health care professionals, using various organization behavior theories. Examples of the types of theory used are Jungian archetypes, scapegoating and mutual negative stereotyping, the Karpman Drama Triangle, and Wells' `group-as-mother' analogue.

Implications of US Managed Care for the British NHS: A Personal View

Implications of US Managed Care for the British NHS: A Personal View

Relationship Between National Institutes of Health Research Awards to US Medical Schools and Managed Care Market Penetration

Moy, Ernest; Mazzaschi, Anthony J.; Levin, Rebecca J.; Blake, David A.; Griner, Paul F. Author Information

Relationship Between National Institutes of Health Research Awards to US Medical Schools and Managed Care Market Penetration

Medical research conducted in academic medical centers is often dependent on support from clinical revenues generated in these institutions. Anecdotal evidence suggests that managed care has the potential to affect research conducted in academic medical centers by challenging these clinical revenues. To examine whether empirical evidence supports a relationship between managed care and the ability of US medical schools to sustain biomedical research. Data on annual extramural research grants awarded to US medical schools by the National Institutes of Health (NIH) from fiscal years 1986 to 1995 were obtained, and each medical school was matched to a market for which information about health maintenance organization (HMO) penetration in 1995 was available. Growth in total NIH awards, traditional research project (R01) awards, R01 awards to clinical and basic science departments, and changes in institutional ranking by NIH awards were compared among schools located in markets with low, medium, and high managed care penetration. Medical schools in all markets had comparable rates of growth in NIH awards from 1986 to 1990. Thereafter, medical schools in markets with high managed care penetration had slower growth in the dollar amounts and numbers of NIH awards compared with schools in markets with low or medium managed care penetration. This slower growth for schools in high managed care markets was associated with loss of share of NIH awards, equal to $98 million in 1995, and lower institutional ranking by NIH awards. Much of this revenue loss can be explained by the slower growth of R01 awards to clinical departments in medical schools in high managed care markets. These findings provide evidence of an inverse relationship between growth in NIH awards during the past decade and managed care penetration among US medical schools. Whether this association is causal remains to be determined.