Drug utilization review in the managed care environment

Area of Science:

• Health Services Research
• Pharmaceutical Policy

Background:

• Traditional drug use evaluation (DUE) and Medicaid drug utilization review (DUR) models are inadequate for managed care organizations.
• Developing new quality measurement systems like HEDIS may discard valuable existing clinical frameworks.

Purpose of the Study:

• To propose an improved approach for drug utilization review (DUR) and drug use evaluation (DUE) within managed care settings.
• To enhance the effectiveness of DUR/DUE by integrating managed care strengths with clinical criteria.

Main Methods:

• Utilizing managed care's strengths: advanced electronic data management, integrated healthcare system interchange, and robust customer communication.
• Combining clinical criteria with sophisticated healthcare management strategies.

Main Results:

• Managed care organizations can enhance DUR/DUE processes by adopting their core competencies.
• A synergistic approach integrating clinical data with management systems can significantly improve drug use oversight.

Conclusions:

• Managed care organizations should adapt existing DUR/DUE frameworks using their technological and systemic advantages.
• Integrating clinical evidence with advanced healthcare management offers a revolutionary path for optimizing drug utilization and evaluation.