Asthma and the Role of Managed Care Pharmacy

Kristy Pezzino, PharmD

Managed care organizations (MCOs) allocate resources to improve the quality of asthma care while controlling asthma-related drug costs. MCOs that are accredited by the National Committee for Quality Assurance (NCQA) focus on Healthcare Effectiveness Data and Information Set (HEDIS) measures to develop management strategies for drugs. NCQA-accredited MCOs strive to create and maintain a drug formulary that offers value to the member; value is defined as outcomes relative to costs.¹ HEDIS measures are divided into 2 categories: (1) preventive care and (2) condition-specific care. The targeted areas for condition-specific care focus on asthma, cardiac conditions, chronic obstructive pulmonary disease, depression, diabetes, mental illness, rheumatoid arthritis, tobacco use, and alcohol and drug abuse.² The 2015 HEDIS measures for asthma include the use of appropriate medications and medication management.³ The HEDIS quality metrics and the overall value of the drug are taken into consideration when managed care pharmacy teams develop utilization management strategies to address pharmacy costs. The main article in this publication provides an excellent update for healthcare professionals regarding asthma and its prevalence, pathophysiology, and economic burden. The prevalence of asthma continues to rise along with treatment-related costs. The pathophysiology of asthma remains a complex subject, with treatment still focused on controlling symptoms rather than halting disease progression. Therefore, managing patients with asthma continues to focus on symptom control and avoidance of triggers of an exacerbation. The economic burden of asthma is well known. Outpatient visits, emergency department visits, and hospitalizations are the key drivers of asthma-related costs. To reduce these costs and improve patient outcomes, MCOs have established disease state management programs that utilize case managers and drug formulary designs, such as Pitney Bowes’s value-based benefit design.⁴ In order to effectively manage asthma at the health plan level, multiple departments within the organization need to work together to achieve a common goal. On the pharmacy side, a managed care’s annual drug spending and patient compliance to medication regimens are monitored, using formulary design and management techniques to provide cost-effective options for patients. Pharmacy departments work with medical management departments to identify patients who are over- or underutilizing medications in an effort to reduce exacerbations that lead to hospitalization. Using claims data on the pharmacy and medical side allows the health plan to apply resources in the most effective manner. Asthma disease progression is based on genetic and environmental factors. By understanding the disease process and identifying allergens that trigger asthma attacks, patients can better manage their symptoms. As novel targeted therapies continue to be developed, health plans are monitoring pipeline drug development to prepare for potential new therapies that will target asthma disease progression. It is hoped that these advances will lead to improved outcomes for patients with this disorder.

References

1. Porter ME. What is value in health care? N Engl J Med. 2010;363:2477-2481.
2. National Quality Measures Clearinghouse. Measure summary. www.qualitymeasures.ahrq.gov/content.aspx?id=47279. Accessed November 26, 2014.
3. National Committee for Quality Assurance. Summary table of measures, product lines and changes. www.ncqa.org/Portals/0/HEDISQM/Hedis2015/List_of_HEDIS_2015_Measures.pdf. Accessed November 26, 2014.
4. Mahoney JJ. Value-based benefit design: using a predictive modeling approach to improve compliance. J Manag Care Pharm. 2008;14(6 Suppl B):3-8.

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