Is an accreditation program needed for PBMs?

October 23, 2006

Should pharmacy benefit management programs meet quality standards? URAC, a Washington, D.C.-based healthcare quality group, has formed a Pharmacy Benefit Management Standards Committee to look into this matter. Its goal is to develop an accreditation program for PBMs and health plans alike.

Heading up the 34-member committee is John Jones, R.Ph., JD, VP of government affairs and pharmacy policy at Prescription Solutions, a PBM based in Irvine, Calif., and part of Ovations Pharmacy Solutions, representing a wide range of players in the PBM field. The committee has met twice and will meet again in December to review the initial draft of the standards, which is expected to be out for public comment this month. It will create standards for four related accreditation programs for health plans and PBMs providing services to both Medicare and commercially insured populations.

URAC's goal is to complete the development process and launch the accreditation programs by mid-2007 following live beta testing, which is scheduled to begin after the first of the year.

Under the committee heading, two subcommittees have been formed to study quality gaps and medical management in PBM programs and to evaluate consumer empowerment through these programs. These two separate work groups initiated efforts to create standards falling within two broad categories. The Operations Work Group has discussed standards for operational integrity, communications, customer service and disclosure, and pharmacy network. The Clinical Work Group has discussed drug use management, benefit design administration, patient safety, formulary development, and medication therapy management.

"We want to create an accreditation program for both the commercial and the Medicare markets that promotes industry best practices, encourages quality improvement, and protects and empowers consumers," said Alan Spielman, president and CEO of URAC. "When fully implemented, we expect there to be four separate programs: two for the PBM entities and two for health plans."

According to Spielman, there are four main factors driving the formation of the committee and the development of the standards and the anticipated accreditation programs: the impact of prescription drugs and prescription drug management; the evolution of the pharmacy benefit industry and its programs; public arena discussion, which Spielman categorizes as "litigation, confusion, and controversy"; and Medicare Part D.

"For the plans and the PBMs, we see this effort as providing an external validation of organizational excellence," said Spielman. "We also see it as providing benchmarks and as a continuous quality improvement oriented process by which companies can improve their operations and enhance their compliance with regulatory standards. Just as important, we see it as reducing misperceptions about PBMs."

Jones told Drug Topics that employers have embraced this effort, and the PBMs have "determined that it would serve them well to make certain best practices are being followed. PBMs are also getting tired of addressing legislation on a state-by-state basis and having industrywide standards may be a better option."

Express Scripts, one of the nation's largest PBMs, said that it is pleased to be part of the standards development process but also offered that it is too early in the process to determine whether it plans to seek accreditation in the program. Medco echoed these sentiments, saying it looked forward to URAC's implementation of a PBM accreditation program and when it becomes available, the PBM giant will assess its interest in pursuing it. A Caremark Rx spokesman noted that the PBM is participating in the committee to "ensure the standards are appropriate for the industry."

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