Patients' Bill of Rights
Kant Patel, Mark E. Rushefsky in Health Care Policy in an Age or New Technologies, 2015
One response to the litany of complaints about managed care has come from the trade association of managed care plans, the AAHP. This is an initiative, adopted in 1996, known as “putting patients first.” The initiative, and the philosophy of care that accompanies it, is designed, according to its supporters, to provide a set of criteria for judging plan performance. Further, AAHP member plans must accept the philosophy and initiative (Jones 1997). Consider two examples of how this philosophy is supposed to work. The first has to do with providing subscribers full information about a plan’s policies: [The AAHP] broadly affirmed that health plans should (1) routinely inform members about their plan’s structure and provider network; the benefits covered and excluded, including out-of-area and emergency coverage; and cost-sharing requirements; and (2) provide information about precertification and other utilization review procedures; the basis for a specific utilization review decision with which a member disagrees, whether a specific prescription drug is included in a formulary; a summary description of how physicians are paid, including financial incentives (short of disclosing specific details of individual financial arrangements); and the procedures and criteria used to determine whether experimental treatments and technologies are covered. (Jones 1997, 118)
F
Alan Earl-Slater in Dictionary of Health Economics, 2018
A list of goods or services that meet certain criteria of acceptance. Usually considered as those goods and services that are eligible for use or those that will be reimbursed by the healthcare financier. For example, most hospitals have a restricted list of medicines that can be used in their setting. A formulary is one way of making explicit the selection of medicines to be used by the health professionals. Underlying the idea of a medicines formulary are concerns about making good use of resources, controlling medicine activity and therefore, to an extent, medicine expenditure. The criteria to get on a formulary, the reasons for delisting, who designed the formulary and the scope of the formulary are some of the issues to consider. Sometimes called a positive list. SeeBlacklist; Negative list; Positive list.
Pain Management and Managed Care: Managing the System
Michael E. Schatman in Ethical Issues in Chronic Pain Management, 2016
An additional problem is that under managed care, available drugs are limited to those specified on managed care drug formularies. In a formulary, the managed care entity will only pay for certain drugs and will not provide medications as written unless the type of drug is not on the formulary. Patients can obtain approval for nonformulary drugs if it can be demonstrated that there is a specific need for the nonformulary drug and the formulary drug will cause harm, either by its very nature, or by its ineffectiveness. Although formularies have achieved cost containment and changes in the behavior of physicians prescribing medications, while at the same time maintaining quality of care, these changes have primarily occurred in inpatient settings. Physicians in outpatient settings and their patients identify less success in the use of formularies and their medications, with cost containment much more limited. Additionally, these critics further identify that the development of formularies may be based more on financial alliances between pharmaceutical companies and the insurance industry rather than effective patient care (6).
New and emerging pharmacotherapy for duchenne muscular dystrophy: a focus on synthetic therapeutics
Published in Expert Opinion on Pharmacotherapy, 2020
Sharon M. Grages, Michael Bell, Daniel J. Berlau
Eteplirsen was initially rejected for FDA approval, citing inadequate results based on a 6MWT. Researchers regrouped, appealing that levels of dystrophin had increased in patients, indicating that with enough time, patients would begin to display improvement. The FDA, through a split and controversial ruling, granted an accelerated and conditional approval with the condition that trials continue. Results from the FDA mandated clinical trial are due in 2021 for reevaluationthe of eteplirsen’s FDA standing.[62] Due in part to the skepticisms surrounding FDA approval, many insurance companies are hesitant to accept the medication into formulary, leaving the medication somewhat cost-prohibitive for most patients and delaying possible treatment in the DMD population. These difficulties, combined with pressure from patient advocacy groups, demonstrates the need for more access to investigational medications to patients without the pressure of rushed findings or pressured approval on the FDA.
Strategies commercially-insured families use to manage the cost of asthma care: a qualitative interview study
Published in Journal of Asthma, 2023
Melissa B. Gilkey, Lauren A. Cripps,, Kathryn M. Przywara, Mikaela I. Batista,, Alison A. Galbraith,
Participants also used consumer behaviors to navigate their health insurance. This type of shopping most often involved switching medications to take advantage of a lower-cost, preferred-tier drug within a given plan’s formulary or submitting prior authorizations requests to seek coverage for a medication. One participant explained: [My daughter’s] doctor [called in] a prescription for her, and I went to the pharmacy to get it, and the insurance company wasn’t covering that particular brand. So I had to go back to their formulary and find out what they would cover and get that medication.—Parent of child with asthma In addition to switching medications, participants described timing their asthma care use to “stock up” on their prescriptions after meeting their annual deductible, as well as shopping across health plans during open enrollment to select the plan with the most cost-effective benefits for asthma. These options were constrained, however; not all participants had health plans that allowed them to fill multiple months of their prescriptions or employers who offered a choice in health plan.
Assessing the Application of Pharmacoeconomic Evaluations in Medicines Management by Hospital Pharmacists in Nigeria: A Cross-Sectional Survey
Published in Hospital Topics, 2023
Theophilus Ehidiamen Oamen, Kanayo Patrick Osemene, Romanus Maduabuchi Ihekoronye
In most low- and medium-income countries (LMICs), the health systems are relatively weak, characterized by inequities, budgetary and human resource constraints, and dependence, to a large extent, on donor funds for certain critical primary health care services, including routine immunizations (Sibeudu, Uzochukwu, and Onwujekwe 2017). Adoption of pharmacoeconomic evaluations as decision support tools in medicines management is still nascent. In Nigeria, healthcare financing mechanisms are such that funding for medicines supplies to public sector health facilities depend largely on budgetary allocations, supported by donor funds (Mohammed 2020). Since healthcare is a concurrent responsibility of both Federal and States governments, there is a significant disparity in the integrity of medicines supply pipelines between Federal and States-owned health facilities and across States, reflecting differences in financial capacities and management effectiveness (Mohammed 2020). These differences have important implications for formulary decisions and medicines management, requiring more of pharmacoeconomic evidence.
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