SUMMER  2001 
Volume 6 / Number 3

Utilization Management Workshop

Christopher Goff, JD, MA, Employer Health Purchasing Corporation of Ohio
Edward Lane, Consultant, Hewitt Associates
Susan Peard, Principal, Pharmacy Outcomes Specialists

The team of Goff, Lane and Peard approached the subject of Utilization Management from three very distinct perspectives. Chris Goff represents over 100 employer purchasing groups nationwide. Chris shared a quandrant analysis technique that allows his organization to compare annual price inflation and market share for drugs within a therapeutic class, categorize the data and see the distribution pattern for trend analysis and formulary management. The drug categories focused on in this session included: Statins, Antihypertensives, Leukotriene modifiers (asthma), non-sedating antihistimines, BPH-benigng prostatic hypertrophy, antidepressants, Tryptans (migraine), and G.I. These categories were chosen because they represent notable volume and cost, they are frequently managed, and represent long established categories.

Ed Lane approached the subject of utilization management from the coverage terms and limitations perspective. In designing prescription drug benefit, plan sponsors need to determine how it fits in with the overall medical benefit philosophy. Plan coverage rules must be coordinated along with the clinical quality management rules. Examples include: Prospective drug utilization review (incentive formularies, high cost case management, prior authorization, and step protocols), concurrent drug utilization review, retrospective drug utilization review, including physician profiling and detailing and finally, targeted disease management and intervention.

Susan Peard discussed the issues and objectives related to understanding utilization management this way, "PBMs do no have incentives to reduce the number of prescription therapies. You need to control behavior to control cost." She also discussed the need to provide physicians and patients with "real" information. HIPAA guidelines, as they relate to utilization, will also require attention and discussion. To this point, Peard believes that utilization will be the driver of increased costs over the next five years.

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