Balancing the cost and value of medications: the dilemma facing clinicians

In the current complex healthcare environment, considerations of medication efficacy, risk, cost, reimbursement, and regulation compete to influence the physician's clinical decision making in an atmosphere marked by curtailed physician autonomy, adversarial doctor-patient relationships, and conflict between clinical and managerial goals. Often, pharmaceutical expenditures are managed as if they exist in a universe separate from that occupied by all other aspects of patient care, even when a societally based cost-effectiveness analysis might favour more aggressive use of drug therapy for the long-term benefits it can generate. One response to these conflicting pressures is the creation of institutional resources to help reconcile the inevitable conflicts between such forces. At the author's institution, the Brigham and Women's Hospital, a new clinical Division of Pharmacoepidemiology and Pharmacoeconomics seeks to develop a reservoir of expertise to address the issue of appropriate medication use in a proactive way. Its goal is to help the hospital remain on the cutting edge of therapeutics while containing its drug budget within reasonable bounds. The programme consists of a system of ongoing formulary review, surveillance of current prescribing patterns, the production of educational monographs, a computer-based order entry system, a curriculum on cost effectiveness for interns, residents and medical students, and deployment of hospital-based 'detailers' to discuss problematical prescribing decisions with practitioners. The dissemination of such an approach in multiple sectors of the healthcare system could lead to greater sophistication by payers, prescribers, patients, and policy makers concerning how best to balance benefits, risks, and costs in pharmacotherapy.