Integrating E-Prescribing and Pharmacy Claims Data for Predictive Modeling: Comparing Costs and Utilization of Health Plan Members Who Fill Their Initial Medications with Those Who Do Not.

BACKGROUND: Nonfilling of prescribed medications is a worldwide problem of serious concern. Studies of health care costs and utilization associated with medication nonadherence frequently rely on claims data and usually focus on patients with specific conditions. Past studies also have little agreement on whether higher medication costs associated with higher adherence can reduce downstream health care consumption. OBJECTIVES: To (a) compare the characteristics between people with and without complete medication initiations from a general population and (b) quantify the effect of medication initiation on health care utilization and expenditures with propensity score weighting. METHODS: We conducted a retrospective cohort study using 2012 and 2013 electronic health records (EHR) and insurance claims data from an integrated health care delivery network. We included 43,097 eligible primary care patients in the study. Annual medication fill rates of initial prescriptions in 2012 were defined as the number of filled prescriptions from claims divided by the number of e-prescriptions from EHRs, while excluding all refills. A claim was considered filled if (a) EHR and claims records were from the same drug class; (b) claims occurred between the date of a current EHR order and that of the next EHR order of the same class; and (c) the maximum fill rate was 100%. The 6 annual outcomes included total costs, medical costs, pharmacy costs, being a high-cost "outlier" (in top 5%), having 1 or more hospitalizations, and having 1 or more emergency department (ED) visits. Individuals were classified as either having completed all medication initiations (100% annual filling rate for initiations) or not. We used propensity score weighting to control for baseline differences between complete and incomplete initial fillers. We adopted linear and logistic regressions to model costs and binary utilization indicators for the same year (concurrently) and next year (prospectively). RESULTS: Approximately 42% of the study sample had complete medication initiations (100% filling rate), while the remaining 58% had incomplete initiations. Individuals who fully filled initial prescriptions had lower comorbidity burden and consumed fewer health care resources. After applying propensity score weighting and controlling for variables such as the number of prescription orders, patients with complete medication initiations had lower overall and medical costs, concurrently and prospectively (e.g., $751 and $252 less for annual total costs). Complete medication initiation fillers were also less likely to have concurrent health care utilization (OR = 0.78, 95% CI = 0.68-0.90 for hospitalization; OR = 0.77, 95% CI = 0.72-0.82 for ED admissions) but no difference in prospective utilization other than for ED visits (OR = 0.93, 95% CI = 0.87-0.99). CONCLUSIONS: Identifying the subpopulation of patients with incomplete medication initiations (i.e., filling less than 100% of initial prescriptions) is a pragmatic approach for population health management programs to align resources and potentially contain cost and utilization. DISCLOSURES: No outside funding supported this study. This study applied the Adjusted Clinical Group (ACG) case-mix/risk adjustment methodology, developed at Johns Hopkins Bloomberg School of Public Health. Although ACGs are an important aspect of this study, the goal of the study was not to directly assess or evaluate the methodology. The Johns Hopkins University receives royalties for nonacademic use of software based on the ACG methodology. Chang, Kharrazi, and Weiner receive a portion of their salary support from this revenue. Chang is also a part-time consultant for Monument Analytics, a health care consultancy whose clients include the life sciences industry, as well as plaintiffs in opioid litigation. Alexander is past Chair of FDA's Peripheral and Central Nervous System Advisory Committee; has served as a paid advisor to IQVIA; is a co-founding Principal and equity holder in Monument Analytics; and is a member of OptumRx's National P&T Committee. These arrangements have been reviewed and approved by Johns Hopkins University in accordance with its conflict of interest policies. The other authors have nothing to disclose.

Medication Therapy Management: 10 Years of Experience in a Large Integrated Health Care System.

BACKGROUND: Medication therapy management (MTM) was officially recognized by the federal government in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, which requires Medicare Part D plans that offer prescription drug coverage to establish MTM programs (MTMPs) for eligible beneficiaries. Even though the term "MTM" was first used in 2003, pharmacists have provided similar services since the term "pharmaceutical care" was introduced in 1990. Fairview Health Services, a large integrated health care system, implemented a standardized pharmaceutical care service system in 1998, naming it a pharmaceutical care-based MTM practice in 2006. OBJECTIVE: To present the clinical, economic, and humanistic outcomes of 10 years of delivering MTM services to patients in a health care delivery system. METHODS: Data from MTM services provided to 9,068 patients and documented in electronic therapeutic records were retrospectively analyzed over the 10-year period from September 1998 to September 2008 in 1 health system with 48 primary care clinics. Patients eligible for MTM services were aged 21 years or older and either paid for MTM out of pocket or met their health care payer's criteria for MTM reimbursement; the criteria varied for Medicaid, Medicare, and commercially insured enrollees. All MTM was delivered face to face. Health data extracted from the electronic therapeutic record by the present study's investigators included patient demographics, medication list, medical conditions, drug therapy problems identified and addressed, change in clinical status, and pharmacist-estimated cost savings. The clinical status assessment was a comparison of the first and most recent MTM visit to measure whether the patient achieved the goals of therapy for each medical condition (e.g., the blood pressure of a patient with diabetes and hypertension will be less than 130/80 millimeters mercury [mmHg] in 1 month; the patient with allergic rhinitis will be relieved of his complaints of nasal congestion, runny nose, and eye itching within 5 days). Goals were set according to evidence-based literature and patient-specific targets determined cooperatively by pharmacists, patients, and physicians. Cost-savings calculations represented MTM pharmacists' estimates of medical services (e.g., office visits, laboratory services, urgent care visits, emergency room visits) and lost work time avoided by the intervention. All short-term (3-month) estimated health care savings that resulted from addressing drug therapy problems were analyzed. The expenses of these avoided services were calculated using the health system's contracted rates for services provided in the last quarter of 2008. The return on investment (ROI) was calculated by dividing the pharmacist-estimated savings by the cost of MTM services in 2008 (number of MTM encounters times the average cost of an MTM visit). The humanistic impact of MTM services was assessed using the results from the second patient satisfaction survey administered in 2008 (new patients seen from January through December 2008) for the health system's MTM program. RESULTS: A total of 9,068 patient records were in the documentation system as of September 30, 2008. During the 10-year period, there were 33,706 documented encounters (mean 3.7 encounters per patient). Of 38,631 drug therapy problems identified and addressed by MTM pharmacists, the most frequent were a need for additional drug therapy (n = 10,870, 28.1%) and subtherapeutic dosage (n = 10,100, 26.1%). In the clinical status assessment of the 12,851 medical conditions in 4,849 patients who were not at goal when they enrolled in the program, 7,068 conditions (55.0%) improved, 2,956 (23.0%) were unchanged, and 2,827 (22.0%) worsened during the course of MTM services. Pharmacist-estimated cost savings to the health system over the 10-year period were $2,913,850 ($86 per encounter) and the total cost of MTM was $2,258,302 ($67 per encounter), for an estimated ROI of $1.29 per $1 in MTM administrative costs. In the patient satisfaction survey, 95.3% of respondents agreed or strongly agreed that their overall health and well-being had improved because of MTM. CONCLUSION: Pharmacist estimates of the impact of an MTM program in a large integrated health care system suggest that the program was associated with improved clinical outcomes and cost savings. Patient satisfaction with the program was high. DISCLOSURES: There was no external funding for this manuscript. The 3 authors are employees of Fairview Pharmacy Services. Ramalho de Oliveira had primary responsibility for the concept and design, writing, and revision of the manuscript, with the assistance of Brummel and Miller. Ramalho de Oliveira performed the data collection, and all 3 authors shared equally in data interpretation.

Cost avoidance related to a pharmacist-led pharmacogenomics service for the Program of All-inclusive Care for the Elderly.

Aim: Estimate cost avoidance of pharmacist recommendations for participants enrolled in the Program of All-inclusive Care for the Elderly. Materials & methods: Convenience sample of 200 pharmacogenomics consultations from the PHARM-GENOME-PACE study. Genetic variants, drug-gene interactions, drug-drug-gene interactions and phenoconversions were interrogated. Cost avoidance was estimated and adjusted for inflation. Results: In total, 165 participants had at least one actionable drug-gene pair totaling 429 drug-gene pairs, of which 158 (36.8%) were clinically actionable. Most (70.5%) pharmacists' recommendations were accepted. Estimated cost avoidance was $233,945 when all recommendations were included but conservatively $162,031 based on acceptance rates. Overall mean cost avoidance per actionable drug-gene pair was $1063 or $1983 per participant. Conclusion: Pharmacist-led pharmacogenomics services added to the traditional medication review can avoid substantial costs for payers. Clinical trial registration number: NCT03257605.

Cost analysis of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy and the risk factors for their increased cost in a public insurance health care system - Single centre study.

INTRODUCTION: This study aimed to evaluate the costs of CRS and HIPEC and treatment of the related postoperative complications in the public healthcare system. We also aimed to identify the risk factors that increase the cost of CRS and HIPEC. MATERIALS AND METHODS: We retrospectively evaluated 80 patients who underwent CRS and HIPEC between February 2016 and November 2018 in the Department of Surgery, University Hospital of Olomouc, Czech Republic. Intraoperative factors and postoperative complications were assessed. The treatment cost included the surgery, hospital stay, intensive care unit (ICU) admission, pharmaceutical charges including medication, hospital supplies, pathology, imaging, and allied healthcare services. RESULTS: The postoperative morbidity rate was 50%, and the mortality rate was 2.5%. The mean length of hospitalisation and ICU admission was 15.44 ± 8.43 and 6.15 ± 4.12 for all 80 patients and 10.73 ± 2.93 and 3.73 ± 1.32, respectively, for 40 patients without complications, and 20.15 ± 13.93 and 8.58 ± 6.92, respectively, for 40 patients with complications. The total treatment cost reached €606,358, but the total reimbursement was €262,931; thus, the CRS and HIPEC profit margin was €-343,427. Multivariate analysis showed that blood loss ≥1.000 ml (p = 0.03) and grade I-V Clavien-Dindo complications (p < 0.001) were independently associated with increased costs. CONCLUSION: The Czech public health insurance system does not fully compensate for the costs of CRS and HIPEC. Hospital losses remain the main limiting factor for further improving these procedures. Furthermore, treatment costs increase with increasing severity of postoperative complications.

Reflections on the ISPOR Special Task Force on U.S. Value Frameworks: Implications of a Health Economics Approach for Managed Care Pharmacy.

In 2016, The Professional Society for Health Economics and Outcomes Research (ISPOR) formed a special task force (STF) to review approaches and methods to support the definition and use of high-quality U.S. value frameworks. As the leadership group of that initiative, we present our perspective, focusing on implications for the managed care pharmacy community. Our reflections are organized by 9 key observations and conclude with a summary recommendation. We begin by emphasizing the importance of distinguishing among "perspectives" and "decision contexts." Possible perspectives include patient, payer, provider, health care sector, and societal. Decision contexts range from formulary inclusion to guideline development to clinical shared decision making, and multiple perspectives can be taken on each of these decisions. The STF focused on value in the context of including a new medicine in a formulary and, thus, health plan, using a health economics approach that compares marginal benefit (gross value) and marginal (opportunity) cost, yielding the net value. Health care is unique compared with other markets. While economists often use market purchases as indicators of value, they also recognize that this does not work well in health care, since most patent-protected drugs are covered by insurance. To assess the likely health and economic impact, health economists often employ cost-effectiveness analysis, using the quality-adjusted life-year (QALY), a metric that combines mortality and morbidity into a single preference-based index. We strongly endorse the STF's recommendation that payers should use the cost-per-QALY metric as a starting point. However, like the STF, and many of those stakeholders who provided input, we recognize that this metric has some limitations in theory and in practice. Nonetheless, the cost-per-QALY metric is a pragmatic tool that can be augmented to address some of its limitations by integrating other elements of value, particularly those related to uncertainty, such as financial risk protection, health risk protection, the value of hope, real option value, and the value of knowing. The resulting adjusted ratio can be compared with a willingness-to-pay threshold or combined in a measure of net monetary benefit. Alternatively, the array of elements can be valued using multi-criteria decision analysis. We end with the key recommendation that further development and testing of these promising approaches is needed to improve the deliberative process of health technology assessment. DISCLOSURES: No outside funding supported the writing of this article. The authors are leaders of the ISPOR Special Task Force on U.S. Value Frameworks. Willke is employed by ISPOR. Garrison and Neumann have nothing to disclose. The opinions expressed in this article should be considered as belonging only to the authors.

AMCP Partnership Forum: Integrated Delivery Networks' Role in Pharmaceutical Value-Based Agreements.

Health care payment models that reward value over volume have the potential to improve patient care and control rising costs. These payment models are increasingly being implemented by a range of care delivery providers in the United States. Integrated delivery networks (IDNs)-systems of providers and sites (e.g., group practices and hospitals) that care for and provide health care services and health insurance plans to patients in a specific region or market-present special opportunities and challenges for value-based care and represent an important sector for the advancement of value-based models. Successful implementation of value-based agreements in IDNs requires a range of complex capabilities, including advanced data analytics, population health management solutions, comprehensive care management, and successful patient engagement. To address these and other operational issues, the Academy of Managed Care Pharmacy convened a stakeholder forum on November 13-14, 2018, in Baltimore, MD. Forum attendees addressed topics including (a) the current delivery of value-based care in IDNs; (b) opportunities and barriers to implementing pharmaceutical value-based agreements; (c) recommendations for IDNs to reach the full potential of value-based agreements; and (d) opportunities for collaborations among managed care organizations, accountable care organizations, and IDNs to improve health care outcomes. Thought leaders with a wide range of backgrounds attended the forum, including those representing patients, payers, providers, government, and biopharmaceutical companies. The forum was sponsored by Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Genentech, Lilly, MedImpact, Merck, National Pharmaceutical Council, Novo Nordisk, Pharmaceutical Research and Manufacturers of America, Takeda, and Xcenda. This proceedings document presents common themes and comments from individual participants at the forum, which are not necessarily endorsed by all attendees, nor should they be construed to reflect group consensus. DISCLOSURES: This AMCP Partnership Forum and the development of this proceedings document were supported by Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Genentech, Lilly, MedImpact, Merck, National Pharmaceutical Council, Novo Nordisk, Pharmaceutical Research and Manufacturers of America, Takeda, and Xcenda.

Clinical and economic impacts of clinical pharmacists' interventions in Iran: a systematic review.

OBJECTIVES: There are many studies about Iranian clinical pharmacists' interventions and their impacts on medication safety and cost. The aim of this study is to collect data and critically evaluate the clinical and economic effects of Iranian clinical pharmacist interventions and activities. To our best of knowledge, this research is the first review of publications about Iranian clinical pharmacists' interventions and activities. EVIDENCE ACQUISITION: Six online databases, including PubMed, Scopus, Medline, Cochrane Central Register of Controlled Trials, Cochrane Database of Systemic Reviews, and Google Scholar were searched using the terms '"Iranian", "clinical pharmacist", 'adverse drug reactions", "medication errors", "drug interaction", "drug utilization evaluation", "cost", and "interventions" for English studies conducted in Iran and described clinical pharmacist-initiated interventions, published before December 2018. The search and extraction process followed PRISMA guidelines. Observational or retrospective studies, clinical trials, congress abstracts, and case reports or case series were excluded. The search strategy after full-text review identified 39 articles matching the eligibility criteria. RESULTS: Thirty-nine articles were recruited. They included establishing pharmaceutical care in out-patient clinics and drug information centers (n = 4); prevention, detection, and management of adverse drug reactions(n = 4), designing protocols and improving drug utilization pattern(n = 16), prevention, detection, and management of medication errors (n = 11), and all clinical pharmacist services(n = 4). Most clinical pharmacist interventions and activities were regarding designing protocols, improving drug utilization pattern, as well as detection, prevention, and management of medication errors. About three-fourth (74.35%) of included studies were from either ambulatory care or in-patient settings in Tehran. The median (interquartile range) duration of intervention as well as follow-up phases was 9 (5) months. CONCLUSION: Data of our review support the beneficial role of clinical pharmacists in the improvement of quality, safety, and efficiency of patients' pharmaceutical care in Iran. Graphical abstract Clinical pharmacists' interventions in Iran.

Incident-to Billing for Pharmacists.

The inclusion of pharmacists on care teams has been shown to improve clinical and economic health outcomes. However, a significant barrier to the widespread incorporation of pharmacists into care teams is the ability to financially support the salary of the pharmacist. A mechanism to improve the ability of pharmacists to generate clinical revenue already exists in the form of incident-to billing, although there remains considerable uncertainty regarding the criteria for incident-to billing and specifically how pharmacists can use this model to capture revenue for clinical services. In this article, we discuss incident-to billing criteria as it pertains to outpatient clinics, common misconceptions related to incident-to billing, and how clinical pharmacists may use this mechanism to generate revenue for the clinical services they provide. DISCLOSURES: This work was not supported by any funding source. The authors have no relevant conflicts of interest to disclose.

Projection of future pharmacy service fees using the dispensing claims in hospital and clinic outpatient pharmacies: national health insurance database between 2006 and 2012.

BACKGROUND: Predicting pharmacy service fees is crucial to sustain the health insurance budget and maintain pharmacy management. However, there is no evidence on how to predict pharmacy service fees at the population level. This study compares the status of pharmacy services and constructs regression model to project annual pharmacy service fees in Korea. METHODS: We conducted a time-series analysis by using sample data from the national health insurance database from 2006 and 2012. To reflect the latest trend, we categorized pharmacies into general hospital, special hospital, and clinic outpatient pharmacies based on the major source of service fees, using a 1% sample of the 2012 data. We estimated the daily number of prescriptions, pharmacy service fees, and drugs costs according to these three types of pharmacy services. To forecast pharmacy service fees, a regression model was constructed to estimate annual fees in the following year (2013). The dependent variable was pharmacy service fees and the independent variables were the number of prescriptions and service fees per pharmacy, ratio of patients (≥ 65 years), conversion factor, change of policy, and types of pharmacy services. RESULTS: Among the 21,283 pharmacies identified, 5.0% (1064), 4.6% (974), and 77.5% (16,340) were general hospital, special hospital, and clinic outpatient pharmacies, respectively, in 2012. General hospital pharmacies showed a higher daily number of prescriptions (111.9), higher pharmacy service fees ($25,546,342), and higher annual drugs costs ($215,728,000) per pharmacy than any other pharmacy (p <  0.05). The regression model to project found the ratio of patients aged 65 years and older and the conversion factor to be associated with an increase in pharmacy service fees. It also estimated the future rate of increase in pharmacy service fees to be between 3.1% and 7.8%. CONCLUSIONS: General hospital outpatient pharmacies spent more on annual pharmacy service fees than any other type of pharmacy. The forecast of annual pharmacy service fees in Korea was similar to that of Australia, but not that of the United Kingdom.

Clinical and Economic Benefits of Pharmacist Involvement in a Community Hospital-Affiliated Patient-Centered Medical Home.

BACKGROUND: The primary goals of an accountable care organization (ACO) are to reduce health care spending and increase quality of care. Within an ACO, pharmacists have a unique opportunity to help carry out these goals within patient-centered medical homes (PCMHs). Pharmacy presence is increasing in these integrated care models, but the pharmacist's role and benefit is still being defined. OBJECTIVE: To exhibit the clinical and economic benefit of pharmacist involvement in ACOs and PCMHs as documented by clinical interventions (CIs) and drug cost reductions. METHODS: This is a retrospective quality improvement study. All interventions made by the pharmacist during the study period were documented using TAV Health. The interventions were then analyzed. Specific identified endpoints included the total number of documented interventions and number of CIs from each category, transition of care (TOC) medication reconciliations performed, discrepancies identified during TOC medication reconciliation, and cost savings generated from generic and therapeutic alternative use. CI categories were collaborative drug therapy management, medication therapy management (MTM), medication reconciliation, patient and provider education, and drug cost management. RESULTS: During the study period (October 2016-March 2017), a pharmacist was in clinic 8 hours per week. Sixty-three patients were included in the study. There were 283 CIs documented, with a majority of the interventions associated with MTM or cost management (94 and 88 CIs, respectively). There were 37 education CIs, 36 TOC medication reconciliations performed, and 28 collaborative drug therapy management CIs. From the 36 TOC medication reconciliations, 240 medication discrepancies were found, with a majority associated with medication omission. A cost savings of $118,409 was gained from generic and therapeutic alternative substitutions. CONCLUSIONS: Clinical benefit of pharmacy services was demonstrated through documented CIs. Pharmacists can have a dramatic and quantitative effect on reducing drug costs by recommending less expensive generic or therapeutic alternatives. Documenting CIs allows pharmacists to provide valuable evidence of avoided drug misadventures and identification of medication discrepancies. Such evidence supports an elevated quality of care. DISCLOSURES: No outside funding supported this study. The authors have nothing to disclose. Study concept and design were contributed by Tate and Hopper, along with Bergeron. Tate collected and interpreted the data, as well wrote the manuscript, which was revised by all the authors.

Financing of Pharmaceutical Services in the municipal management of the Brazilian Unified Health System.

OBJECTIVE: To discuss factors related to the financing of the Basic Component of Pharmaceutical Services within the municipal management of the Brazilian Unified Health System. METHODS: The Pesquisa Nacional sobre Acesso, Utilização e Promoção do Uso Racional de Medicamentos no Brasil - Serviços (PNAUM - National Survey on Access, Use and Promotion of Rational Use of Medicines - Services) is a cross-sectional, exploratory, and evaluative study that performed an information survey in a representative sample, stratified by Brazilian regions It considered different study populations in the sampling plan, which represent primary health care services in the cities. Data were collected in 2015 by two methods: in person, by applying direct observation scripts and interviews with users, physicians, and professionals responsible for the dispensing of medicines in primary care services; by telephone interviews with municipal health managers and municipal professionals responsible for Pharmaceutical Services. The results were extracted from the questionnaires applied by telephone. RESULTS: Of the sample of 600 eligible cities, we collected 369 interviews (61.5%) with secretaries and 507 (84.5%) with pharmaceutical services managers. 70.8% of the cities have a computerized management system; and 11.9% have qualification/training of professionals. More than half (51.3%) of the cities received funds for the structuring of pharmaceutical services, and almost 60% of these cities performed this type of spending. In 35.4% of cases, municipal secretaries of health said that they use resources of medicines from the Componente Básico da Assistência Farmacêutica (CBAF - Basic Component of Pharmaceutical Services) to cover demands of other medicines, but only 9.7% believed that these funds were sufficient to cover the demands. The existence of a permanent bidding committee exclusively for acquiring medicines was reported in 40.0% of the cities. CONCLUSIONS: We found serious deficiencies in the public financing of medicines, as well as little concern about the formality in the use of public resources, expenses that meet individual demands to the detriment of the community, insufficient resources allocated to the Basic Component of Pharmaceutical Services, and exhaustion of the financing model.

Characterization of the institutionalization of pharmaceutical services in Brazilian primary health care.

OBJECTIVE: To characterize the current stage of the institutionalization of pharmaceutical services in Brazilian cities. METHODS: This study is part of the Pesquisa Nacional sobre Acesso, Utilização e Promoção do Uso Racional de Medicamentos (PNAUM - National Survey on Access, Use and Promotion of Rational Use of Medicines), a cross-sectional, exploratory, and evaluative study composed by an information survey in a representative sample of cities, stratified by Brazilian regions. We interviewed municipal secretaries of health, responsible for pharmaceutical services, and pharmacists responsible for the dispensing of medicines. The variables selected from the interviews were grouped into five dimensions that defined three stages of pharmaceutical services institutionalization: incipient (0%-34.0%), partial (35.0%-69.0%), and advanced (70.0%-100%), estimated based on the interviewees' answers. Frequencies were estimated with 95% confidence intervals. For the statistical association analysis, the Chi-square test was applied, with significance level of p<0.05. RESULTS: Our results show a partial and heterogeneous process of institutionalization of pharmaceutical services in Brazil, and an advanced stage in formal structures, such as the municipal health plans and the existence of a standardized list of medicines. The analysed variables in the "organization, structure, and financing" dimension configured stages that range from partial to advanced. The management presented partial institutionalization, positively showing the existence of computerized system, but also disparate results regarding the autonomy in the management of financial resources. Indispensable items related to the structure expressed disparities between the regions, with statistically significant differences. CONCLUSION: The study showed a partial and heterogeneous process of institutionalization of pharmaceutical services in Brazilian cities, showing regional disparities. Variables related to the normative aspects of institutionalization were positively highlighted in all dimensions; however, it is necessary to conduct new studies to evaluate the institutionalization of pharmaceutical services' finalistic activities.

Economic evaluation of the Programs Rede Farmácia de Minas do SUS versus Farmácia Popular do Brasil. / Avaliação econômica dos Programas Rede Farmácia de Minas do SUS versus Farmácia Popular do Brasil.

We conducted an economic assessment of the Pharmaceutical Assistance - Rede Farmácia de Minas Gerais-RFMG and Farmácia Popular do Brasil-FPB to ascertain which of the two models stands out as the most efficient. To do this, a model, which consisted of a study of incurred costs in both programs, up to the dispensing of medicine to citizens, was developed. The uncertainties of the proposed model were tested using the Monte Carlo method. If the entire population initially estimated in the RFMG were attended in the FPB, there would be an additional cost of R$ 139,324,050.19. The sensitivity analysis appeared to be favorable to the RFMG. A total of 10000 simulations were carried out, resulting in a median value of R$ 114,053,709.99 for the RFMG and R$ 254,106,120.65 for the FPB. The current National Drug Policy emphasizes the need to strengthen pharmaceutical services beyond the mere acquisition and delivery of pharmaceutical products. The public healthcare service model, consistent with the principles and guidelines of the SUS, seems to be more appropriate in ensuring complete and universal quality healthcare services to the citizens. The economic study conducted reinforces this fact, as it appears to be a more efficient alternative of the direct use of resources in the public health network.

Avaliação econômica dos Programas Rede Farmácia de Minas do SUS versus Farmácia Popular do Brasil / Economic evaluation of the Programs Rede Farmácia de Minas do SUS versus Farmácia Popular do Brasil

Resumo A fim de esclarecer qual programa de assistência farmacêutica, Rede Farmácia de Minas Gerais RFMG ou Farmácia Popular do Brasil FPB, se apresenta como o mais eficiente sob a perspectiva do financiador público foi realizada uma avaliação econômica. O modelo desenvolvido consiste em um levantamento dos custos incorridos até a dispensação de medicamentos. A análise de Monte Carlo foi utilizada para estimar valores a partir das incertezas. Considerando que a população inicialmente estimada no RFMG fosse atendida em sua totalidade no PFPB, haveria um custo incremental de R$ 139.324.050,19. A análise de Monte Carlo mostrou-se favorável ao RFMG. Foram realizadas 10 mil simulações resultando no valor médio de R$ 114.053.709,99 para RFMG e de R$ 254.106.120,65 para o FPB. O Brasil apresenta uma formulação avançada de políticas públicas na saúde. A Política Nacional de Medicamentos enfatiza a necessidade de fortalecimento da assistência farmacêutica para além da mera aquisição. O modelo público, coerente com princípios e diretrizes do SUS, apresenta-se com condições mais adequadas para garantir assistência integral e universal de qualidade. A avaliação econômica reforça essa afirmativa, pois encontrou maior eficiência na alternativa de aplicação dos recursos diretamente na rede pública.

Abstract We conducted an economic assessment of the Pharmaceutical Assistance - Rede Farmácia de Minas Gerais-RFMG and Farmácia Popular do Brasil-FPB to ascertain which of the two models stands out as the most efficient. To do this, a model, which consisted of a study of incurred costs in both programs, up to the dispensing of medicine to citizens, was developed. The uncertainties of the proposed model were tested using the Monte Carlo method. If the entire population initially estimated in the RFMG were attended in the FPB, there would be an additional cost of R$ 139,324,050.19. The sensitivity analysis appeared to be favorable to the RFMG. A total of 10000 simulations were carried out, resulting in a median value of R$ 114,053,709.99 for the RFMG and R$ 254,106,120.65 for the FPB. The current National Drug Policy emphasizes the need to strengthen pharmaceutical services beyond the mere acquisition and delivery of pharmaceutical products. The public healthcare service model, consistent with the principles and guidelines of the SUS, seems to be more appropriate in ensuring complete and universal quality healthcare services to the citizens. The economic study conducted reinforces this fact, as it appears to be a more efficient alternative of the direct use of resources in the public health network.

Implementation of performance metrics to assess pharmacists' activities in ambulatory care clinics.

PURPOSE: The development and implementation of performance metrics for assessing the impact of pharmacists' activities in ambulatory care clinics are described. SUMMARY: Ambulatory care clinic pharmacists within an integrated health system were surveyed to ascertain baseline practices for documenting and tracking performance metrics. Through literature review and meetings with various stakeholders, priorities for metric development were identified; measures of care quality, financial impact, and patient experience were developed. To measure the quality of care, pharmacists' interventions at five ambulatory care clinics within the health system were assessed. Correlation of pharmacist interventions with estimated cost avoidance provided a measure of financial impact. Surveys were distributed at the end of clinic visits to measure satisfaction with the patient care experience. An electronic system for metric documentation and automated tabulation of data on quality and financial impact was built. In a 12-week pilot program conducted at three clinic sites, the metrics were used to assess pharmacists' activities. A total of 764 interventions were documented (a mean of 24 accepted recommendations per pharmacist full-time equivalent each week), resulting in estimated cost avoidance of more than $40,000; survey results indicated high patient satisfaction with the services provided by pharmacists. Biweekly report auditing and solicitation of feedback guided metric refinement and further training of pharmacists. Tools and procedures were established for future metric expansion. CONCLUSION: Development and implementation of performance metrics resulted in successful capture and characterization of pharmacists' activities and their impact on patient care in three ambulatory care clinics.

Characterization of the institutionalization of pharmaceutical services in Brazilian primary health care / Caracterização da institucionalização da assistência farmacêutica na atenção básica no Brasil

ABSTRACT OBJECTIVE To characterize the current stage of the institutionalization of pharmaceutical services in Brazilian cities. METHODS This study is part of the Pesquisa Nacional sobre Acesso, Utilização e Promoção do Uso Racional de Medicamentos (PNAUM - National Survey on Access, Use and Promotion of Rational Use of Medicines), a cross-sectional, exploratory, and evaluative study composed by an information survey in a representative sample of cities, stratified by Brazilian regions. We interviewed municipal secretaries of health, responsible for pharmaceutical services, and pharmacists responsible for the dispensing of medicines. The variables selected from the interviews were grouped into five dimensions that defined three stages of pharmaceutical services institutionalization: incipient (0%-34.0%), partial (35.0%-69.0%), and advanced (70.0%-100%), estimated based on the interviewees' answers. Frequencies were estimated with 95% confidence intervals. For the statistical association analysis, the Chi-square test was applied, with significance level of p<0.05. RESULTS Our results show a partial and heterogeneous process of institutionalization of pharmaceutical services in Brazil, and an advanced stage in formal structures, such as the municipal health plans and the existence of a standardized list of medicines. The analysed variables in the "organization, structure, and financing" dimension configured stages that range from partial to advanced. The management presented partial institutionalization, positively showing the existence of computerized system, but also disparate results regarding the autonomy in the management of financial resources. Indispensable items related to the structure expressed disparities between the regions, with statistically significant differences. CONCLUSION The study showed a partial and heterogeneous process of institutionalization of pharmaceutical services in Brazilian cities, showing regional disparities. Variables related to the normative aspects of institutionalization were positively highlighted in all dimensions; however, it is necessary to conduct new studies to evaluate the institutionalization of pharmaceutical services' finalistic activities.

RESUMO OBJETIVO Caracterizar o estágio atual da institucionalização da assistência farmacêutica nos municípios brasileiros. MÉTODOS Artigo integrante da Pesquisa Nacional sobre Acesso, Utilização e Promoção do Uso Racional de Medicamentos, um estudo transversal, exploratório, de natureza avaliativa, composto por um levantamento de informações numa amostra representativa de municípios estratificada pelas regiões do Brasil. Foram entrevistados os secretários municipais de saúde, responsáveis pela assistência farmacêutica e farmacêuticos responsáveis pela dispensação dos medicamentos. As variáveis selecionadas das entrevistas foram agrupadas em cinco dimensões, definindo-se três estágios de institucionalização da assistência farmacêutica: incipiente (0-34%), parcial (35%-69%), avançada (70%-100%), estimados com base nas respostas dos entrevistados. Foram estimadas frequências com intervalos de 95% de confiança. Para análise de associação estatística aplicou-se o teste do qui-quadrado, com nível de significância de p < 0,05. RESULTADOS Os resultados mostram um processo heterogêneo e parcial da institucionalização da assistência farmacêutica no Brasil e grau avançado nas estruturas formais, como nos planos municipais de saúde e existência de lista padronizada de medicamentos. As variáveis analisadas na dimensão organização, estrutura e financiamento configuraram estágios que variam de parcial a avançado. A gestão apresentou grau parcial de institucionalização, revelando positivamente a existência de sistema informatizado, e resultados discrepantes no tocante à autonomia na gestão dos recursos financeiros. Itens imprescindíveis relacionados à estrutura expressaram disparidades entre as regiões, com diferenças estatísticas significantes. CONCLUSÕES O estudo mostrou um processo de institucionalização heterogêneo e parcial da assistência farmacêutica em municípios brasileiros, revelando desigualdades regionais. Destacaram-se positivamente as variáveis relacionadas aos aspectos normativos da institucionalização em todas as dimensões, entretanto faz-se necessário novos estudos para avaliar a institucionalização das atividades finalísticas da assistência farmacêutica.

Financing of Pharmaceutical Services in the municipal management of the Brazilian Unified Health System / Financiamento da assistência farmacêutica na gestão municipal do Sistema Único de Saúde

ABSTRACT OBJECTIVE To discuss factors related to the financing of the Basic Component of Pharmaceutical Services within the municipal management of the Brazilian Unified Health System. METHODS The Pesquisa Nacional sobre Acesso, Utilização e Promoção do Uso Racional de Medicamentos no Brasil - Serviços (PNAUM - National Survey on Access, Use and Promotion of Rational Use of Medicines - Services) is a cross-sectional, exploratory, and evaluative study that performed an information survey in a representative sample, stratified by Brazilian regions It considered different study populations in the sampling plan, which represent primary health care services in the cities. Data were collected in 2015 by two methods: in person, by applying direct observation scripts and interviews with users, physicians, and professionals responsible for the dispensing of medicines in primary care services; by telephone interviews with municipal health managers and municipal professionals responsible for Pharmaceutical Services. The results were extracted from the questionnaires applied by telephone. RESULTS Of the sample of 600 eligible cities, we collected 369 interviews (61.5%) with secretaries and 507 (84.5%) with pharmaceutical services managers. 70.8% of the cities have a computerized management system; and 11.9% have qualification/training of professionals. More than half (51.3%) of the cities received funds for the structuring of pharmaceutical services, and almost 60% of these cities performed this type of spending. In 35.4% of cases, municipal secretaries of health said that they use resources of medicines from the Componente Básico da Assistência Farmacêutica (CBAF - Basic Component of Pharmaceutical Services) to cover demands of other medicines, but only 9.7% believed that these funds were sufficient to cover the demands. The existence of a permanent bidding committee exclusively for acquiring medicines was reported in 40.0% of the cities. CONCLUSIONS We found serious deficiencies in the public financing of medicines, as well as little concern about the formality in the use of public resources, expenses that meet individual demands to the detriment of the community, insufficient resources allocated to the Basic Component of Pharmaceutical Services, and exhaustion of the financing model.

RESUMO OBJETIVO Discutir fatores relacionados ao financiamento do Componente Básico da Assistência Farmacêutica no âmbito da gestão municipal do Sistema Único de Saúde. MÉTODOS A Pesquisa Nacional sobre Acesso, Utilização e Promoção do Uso Racional de Medicamentos no Brasil - Serviços é um estudo transversal, exploratório, de natureza avaliativa, que realizou levantamento de dados em amostra estratificada pelas regiões brasileiras, consideradas diferentes populações de estudo no plano de amostragem representativa de serviços de atenção primária em municípios. Os dados foram coletados em 2015, na forma presencial mediante a aplicação de roteiros de observação direta, entrevistas com usuários, médicos e responsáveis pela entrega dos medicamentos nos serviços de atenção primária e entrevistas telefônicas com gestores municipais de saúde e responsáveis municipais pela assistência farmacêutica. Os resultados foram extraídos dos questionários aplicados por telefone. RESULTADOS Da amostra de 600 municípios elegíveis, foram coletadas 369 entrevistas (61,5%) com secretários e 507 (84,5%) com responsáveis pela assistência farmacêutica. Em 70,8% dos municípios existe sistema informatizado de gestão; e em 11,9% qualificação/capacitação dos profissionais. Mais da metade (51,3%) dos municípios receberam recursos destinados à estruturação da assistência farmacêutica, quase 60% desses municípios realizou este tipo de gastos. Em 35,4% dos casos, secretários municipais de saúde afirmaram utilizar recursos de medicamentos do Componente Básico da Assistência Farmacêutica para cobrir demandas de outros medicamentos, mas apenas 9,7% acreditam que esses recursos são suficientes para atender à demanda. A existência de comissão permanente de licitação exclusiva para a aquisição de medicamentos foi registrada em 40,0% dos municípios. CONCLUSÕES São graves as deficiências, a pouca preocupação com a formalidade na execução dos recursos públicos, os gastos ocorridos para atendimento de demandas individuais em detrimento da coletividade, a insuficiência de recursos destinados ao Componente Básico da Assistência Farmacêutica e a exaustão do modelo de financiamento.

[Access to medicines for Alzheimer's disease provided by the Brazilian Unified National Health System in Minas Gerais State, Brazil]. / Acesso aos medicamentos para tratamento da doença de Alzheimer fornecidos pelo Sistema Único de Saúde em Minas Gerais, Brasil.

This study evaluated barriers to access to treatment for Alzheimer's disease based on administrative cases involving cholinesterase inhibitors (ChEIs) and submitted to the Minas Gerais State Health Secretariat in Brazil in 2012 and 2013. Drawing on data from 165 randomly selected cases, the study addressed the following dimensions of access: geographic accessibility, accommodation, acceptability, availability, and affordability. The administrative processing to supply ChEIs took an average of 39 days and was influenced by characteristics of the path taken by the user. The majority of the prescribers met less than 80% of the required criteria in the Clinical Protocol and Therapeutic Guidelines (CPTG) for Alzheimer's disease. As a result, 38% of requests for medication were denied. Private treatment with ChEIs cost the equivalent of 21 days of the monthly minimum wage. In conclusion, bureaucratic administrative procedures and prescribers' difficulty in following the CPTG hindered access to treatment of Alzheimer's disease and imposed a heavy burden on patients' pockets.

Costs of Public Pharmaceutical Services in Rio de Janeiro Compared to Farmácia Popular Program.

OBJECTIVE: To analyze the costs of public pharmaceutical services compared to Farmácia Popular Program (Popular Pharmacy Program). METHODS: Comparison between prices paid by Aqui Tem Farmácia Popular Program (Farmácia Popular is available here) with the full costs of medicine provision by the Municipal Health Department of Rio de Janeiro. The comparison comprised 25 medicines supplied by both the municipal pharmaceutical service and Aqui Tem Farmácia Popular Program. Calculating the cost per pharmaceutical unit of each medicine included expenditure by Municipal Health Department of Rio de Janeiro with procurement (price), logistics, and local dispensation. The reference price of medicines paid by Aqui Tem Farmácia Popular was taken from the Brazilian Ministry of Health standard in force in 2012. Comparisons included full reference price; reference price minus 10.0% copayment by users; and maximum reference paid by the Ministry of Health (minus copayment and taxes). Simulations were carried out of the differences between the costs of Municipal Health Department of Rio de Janeiro with the common medicines and those potentially incurred based on the reference price of Aqui Tem Farmácia Popular. RESULTS: The Municipal Health Department of Rio de Janeiro spent R$28,526,526.57 with 25 medicines of the common list in 2012; 58.7% accounted for direct procurement costs. The estimated costs of the Health Department were generally lower than the reference prices of the Aqui Tem Farmácia Popular Program for 20 medicines, regardless of reference prices. The potential costs incurred by Health Department if expenditure of its consumption pattern were based on the reference prices of Aqui Tem Farmácia Popular would be R$124,170,777.76, considering the best scenario of payment by the Brazilian Ministry of Health (90.0% of the reference price, minus taxes). CONCLUSIONS: The difference in costs between public provision by Municipal Health Department of Rio de Janeiro and Farmácia Popular Program indicates that some reference prices could be reviewed aiming at their reduction. OBJETIVO: Analisar custos da assistência farmacêutica pública frente ao Programa Farmácia Popular. MÉTODOS: Comparação entre os valores pagos pelo Programa Aqui Tem Farmácia Popular com os custos integrais relativos à provisão de medicamentos pela Secretaria Municipal de Saúde do Rio de Janeiro. A comparação compreendeu 25 medicamentos, comuns tanto à provisão pela assistência farmacêutica pública municipal quanto pelo Programa Aqui Tem Farmácia Popular. O cálculo do custo unitário por unidade farmacotécnica de cada medicamento envolveu os gastos da Secretaria Municipal de Saúde com custos de aquisição (preço), logísticos e com a dispensação em nível local. O valor de referência dos medicamentos pago pelo Aqui Tem Farmácia Popular foi extraído da norma ministerial em vigor em 2012. As comparações envolveram o valor de referência pleno; valor de referência com desconto dos 10,0% pagos de contrapartida pelos usuários; e valor de referência máximo pago pelo Ministério da Saúde (descontados contrapartida e sem impostos).Foram realizadas simulações das diferenças entre os gastos da Secretaria Municipal de Saúde do Rio de Janeiro com os medicamentos do elenco comum e os que seriam incorridos se esses tivessem sido executados com base no valor de referência do Aqui Tem Farmácia Popular. RESULTADOS: A Secretaria Municipal de Saúde do Rio de Janeiro gastou R$28.526.526,57 com 25 medicamentos do rol comum em 2012; 58,7% corresponderam a custos diretos com a aquisição dos produtos. Os custos estimados da Secretaria Municipal de Saúde do Rio de Janeiro foram, em geral, menores que os valores de referência do Programa Aqui Tem Farmácia Popular em 20 medicamentos, independentemente dos valores de referência. Os custos que seriam incorridos pela Secretaria Municipal de Saúde do Rio de Janeiro, caso seu padrão de consumo tivesse como valor de pagamento os valores de referência do Aqui Tem Farmácia Popular seriam de R$124.170.777,76 considerando a melhor situação de pagamento pelo Ministério da Saúde (90,0% do valor de referência, com impostos descontados). CONCLUSÕES: A diferença de custos entre a provisão pública pela Secretaria Municipal de Saúde do Rio de Janeiro e o Programa Aqui Tem Farmácia Popular sinaliza que alguns valores de referência poderiam ser objetos de exame para sua redução.