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Iowa Medicaid Preferred Drug List Powerpoint - Iowa Medicaid PDL

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Iowa Medicaid Preferred Drug List Powerpoint  - Iowa Medicaid PDL Powered By Docstoc
					     Iowa Medicaid
Preferred Drug List
   Presented by:
   Timothy Clifford, MD




   September 28 & 29, 2004


                             1
Overview
   Today and next month:
       Review data and evidence to design 1st
        PDL
 This may seem like a daunting task
 Does the PDL need to be perfect?
     No such thing
     Maintenance is fluid and evolutionary



                                              2
The 1st Year
   Together we will create an extensive PDL
    affecting most drug categories
   The 1st year will be relatively simple
       “Relative” may not seem so until next year
       Recommended “easy” approach (despite more
        savings being available through PA approach)
       Base year—subsequent versions will be more
        complex and with the potential for fewer
        choices in order to realize greater savings


                                                   3
Focus for Next Two Days
 Need to keep an open but skeptical
  mind
 Listen carefully and critically
 Concentrate on drugs with draft PDL
  positions that concern you




                                    4
Ranking Drugs
Categorize drugs as:
 Preferred without conditions, or
 Preferred with conditions not involving PA (eg.
  age ranges Ortho-Evra preferred if under 21
  years), or
 Preferred with conditions involving PA (eg.
  Genotropin GH), or
 Non-preferred with all non-preferred drugs
  equal, or
 Non-preferred with same non-preferred drugs
  favored over others (eg. Protonix less non-
  preferred than Prilosec)
                                                    5
PDL Basics
In many PDL categories:
 Although there may be many differences
  in individual responsiveness to any one
  given product, the majority who
  eventually respond to any drug in the
  category will respond to the first drug
  tried
 Law of diminishing returns can be
  validated with utilization data

                                            6
Success Targets
Drug response averages:
 1st product from roughly equivalent
  class works 60 – 65% of the time
 2nd increases to 75 – 85%
 3rd to 85 – 90%
 4th to near 95%
 No matter how many drugs are
  available, it will never be 100%
                                        7
The Initial Drug Selections
Unless there is a need for a particular
characteristic of one drug that is not
present in the others (or vice-versa
with side effects), then the initial
choice should be based on the
average probability of response in the
population (as per studies), since this
cannot be predicted with any greater
certainty at the patient level

                                      8
How to Test Choices
   PA is the best method for testing
    and validating clinical arguments for
    medical necessity based on relative
    risks or relative differences in
    efficacy between preferred and non-
    preferred drugs
       Must be an acceptable cost:benefit
        ratio to curtailing access to initial
        choices

                                                9
PDL Engineering
 There are many different ways to
  create a PDL
 Two different groups can follow the
  same process precisely and arrive at
  a different result
 Two different group can follow
  grossly different rules and reach the
  same results
                                     10
Sorting Through It All
 There is much information and data
  from manufacturers and other
  presenters
 The efficacy or value of the
  manufacturer products to the
  practice of medicine is not in dispute
 Keep it simple and focused on the
  following three key issues
                                      11
Three Keys
1.   Does manufacturer have proof that their
     product is clinically better/safer than preferred
     choices for the majority of the Medicaid
     members—not just subpopulations?
2.   Can manufacturer demonstrate that their
     product is as or more cost-effective than the
     preferred choices?
3.   If the above cannot be shown, then focus on
     what PDL criteria should be in order to access
     the product via the PA process.


                                                     12
PDL vs. PA
   The decision to make a drug preferred or
    non-preferred can be simplified by using
    the three keys as precepts
   The level of clinical complexity necessary
    for a P&T Committee decision on
    preferred status is much different and
    markedly simpler than it is for that
    involved in determining prior
    authorization approval criteria because…

                                             13
Prior Authorization Criteria
   In a PDL, the objective is to designate as
    preferred the most cost-effective drugs
    that will work for the majority of the
    Medicaid population as initial choices
   The PA arm or component of the PDL
    requires a greater level of purely clinical
    reasoning (the issues are different):
       Does this individual (yes/no?) need this
        particular drug (y/n?) for this condition (y/n?)
        at this time (y/n?)?


                                                      14
In Summary…
   The PDL is all about creating an array of
    cost effective drugs that will suffice for
    most patients, most of the time
   All other drugs are available via PA
   Preferred drugs are a set of tools that can
    be used freely and hopefully prudently
    without permissions



                                             15

				
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