Complexities and Challenges in Managed Care

摘要

OBJECTIVES: To (a) summarize the implications of human immunodeficiency virus (HIV) and Hepatitis B virus (HBV) guidelines for managed care, and (b) relate the challenges of caring for HIV, HBV, and HIV-HBV co-infected patients to managed care.SUMMARY: The primary complexity for managed care related to human immunodeficiency virus (HIV) and/or hepatitis B virus (HBV) infection is that treatment guidelines, recommendations, and consensus statements are rapidly changing as new information emerges and that significant uncertainties remain.By 2017, total health care spending will be more than Dollars 4 trillion dollars per year, more than double the current level. One response of managed care is increasing use of cost-management tools, such as treatment guidelines, formulary restrictions, lists of preferred drugs, and implementation of disease management programs. A key component of programs to manage medication use involves the pharmacy benefit design.Altrlus Health/Harvard Vanguard Medical Associates use an algorithm to make formulary decisions that explicitly incorporate the clinical value and cost-effectiveness of proposed additions.CONCLUSIONS: For chronic diseases, such as HIV, HBV, and co-infections with HIV and HBV, an approach that encourages the implementation of strategies to improve the treatment of patients diagnosed with these conditions is needed. This approach should include empowering front-line clinicians in addressing issues around access to, persistence with, and adherence to therapy. The challenge to managed care in antiviral medications for HIV and HBV is similar to that in other chronic medication categories. Managed care organizations must evolve the drug benefit design to provide access to chronic medications that are recommended by evidence-based treatment guidelines and to provide the data to support and empower clinical improvement.