Establishing value in managed care: cost-effectiveness or budgetary impact?

Area of Science:

• Health economics
• Pharmacoeconomics
• Managed care pharmacy

Background:

• Pharmacy benefit managers (PBMs) face challenges in drug coverage decisions within managed care.
• Existing data from randomized controlled trials (RCTs) often fail to compare medications within the same class.
• Comparative trials and pragmatic pharmacoeconomic studies are infrequently conducted.

Purpose of the Study:

• To explore methods for determining drug product superiority for formulary decisions.
• To identify reliable evidence sources for managed care decision-making.
• To assess the limitations of current data and propose alternative evaluation strategies.

Main Methods:

• Review of data sources for drug comparison, including RCTs, naturalistic studies, and economic modeling.
• Analysis of retrospective data from patient surveys and existing databases.
• Evaluation of the consistency of evidence across diverse study types and settings.

Main Results:

• Randomized controlled trials (RCTs) lack comparative data for drugs in the same class.
• Economic modeling presents potential bias concerns.
• Retrospective analyses and a continuum of evidence from basic science to clinical and pharmacoeconomic studies are emerging as valuable tools.

Conclusions:

• A single study type is insufficient for determining drug superiority.
• Consistent evidence of superiority across various study types and patient care settings is critical for informing formulary decisions.
• Healthcare providers rely on consistent, multi-faceted evidence for decision-making.