Process Group

Utilization Management

Objective

• Validate appropriate use of prescribed medicines

• Guard against over-use, under-use and misuse of pharmaceutical therapies and take action to resolve. (Note: PBM is an integral part of UM procedures. It is singled out here in this process matrix because of the inherent threat from escalating drug prices, misuse of drug formulary, and overprescribing habits on the part of some providers)

Input

• Adjudicated claims

• Clinical data

• Pharmacy data

• Known benchmarks

• Number of known patients

Output

• Report on provider utilization of pharmaceuticals versus alternative benchmarks that are culturally accepted

• Letters to provider based on alternative therapies or use of generic drugs

• Lock in member to specific pharmacy

Measurable Outcomes

• X time period report (quarterly) which describes in detail prescribing behavior usually by region, by medical specialty, by facility

• Reduction of cost of pharmacy benefits

• Adherence to use of lower cost medications (generic substitutions)

Sources

• Joint Learning Network, 2012

• File: NHIIS_Phase_1_Public_Report_JLN_IT_Workshop_FINAL_Jan182012_A4.pdf