Research in Social and Administrative Pharmacy 11 (2015) 459–467

Commentary

The Affordable Care Act, health care reform, prescription drug formularies and utilization management tools Brian L. Ung, B.S.*, C. Daniel Mullins, Ph.D. University of Maryland School of Pharmacy, 220 Arch Street, 12th Floor, Baltimore, MD 21201, USA

Summary The U.S. Patient Protection and Affordable Care Act (hence, Affordable Care Act, or ACA) was signed into law on March 23, 2010. Goals of the ACA include decreasing the number of uninsured people, controlling cost and spending on health care, increasing the quality of care provided, and increasing insurance coverage benefits. This manuscript focuses on how the ACA affects pharmacy benefit managers and consumers when they have prescriptions dispensed. PBMs use formularies and utilization control tools to steer drug usage toward cost-effective and efficacious agents. A logic model was developed to explain the effects of the new legislation. The model draws from peer-reviewed and gray literature commentary about current and future U.S. healthcare reform. Outcomes were identified as desired and undesired effects, and expected unintended consequences. The ACA extends health insurance benefits to almost 32 million people and provides financial assistance to those up to 400% of the poverty level. Increased access to care leads to a similar increase in overall health care demand and usage. This short-term increase is projected to decrease downstream spending on disease treatment and stunt the continued growth of health care costs, but may unintentionally exacerbate the current primary care physician shortage. The ACA eliminates limitations on insurance and increases the scope of benefits. Online health care insurance exchanges give patients a central location with multiple insurance options. Problems with prescription drug affordability and control utilization tools used by PBMs were not addressed by the ACA. Improving communication within the U.S. healthcare system either by innovative health care delivery models or increased usage of health information technology will help alleviate problems of health care spending and affordability. Ó 2015 Elsevier Inc. All rights reserved. Keywords: Health care reform; Affordable Care Act; United States healthcare issues; Control utilization tools

Competing interests: The authors declare no potential conflicts of interest, competing interests, or funding sources associated with this manuscript. * Corresponding author. Tel.:þ1 8055016087. E-mail address: [email protected], [email protected] (B.L. Ung). 1551-7411/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.sapharm.2014.08.004

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Introduction Health care reform under the ACA will impact millions of Americans, yet the ripple effects beyond the intended impact are unclear. The ACA is arguably the most comprehensive change to the U.S. health system since the inception of Medicare and Medicaid in 1965. Decreasing the number of uninsured, controlling costs, and increasing the amount of coverage provided by insurance plans are goals of the ACA. Under the ACA, nearly all aspects of the U.S. healthcare system will be affected including the way in which prescription drug coverage benefits are structured for new and currently insured individuals. The ACA will require insurance plans for individuals and small groups to comply with mandated minimum coverage standards set by the state benchmark plan. This formulary requirement is to ensure patient access to care and to increase affordability of medication. However, government mandated formulary requirements in the U.S. have been linked to excess spending, opening the door for increases in the cost of health care for all patients, including those currently with insurance.1 Background The objective of this paper is to examine the impact the ACA may have on health care consumers in the United States when they have prescriptions dispensed. Two key areas that are examined include prescription drug formularies and utilization control measures commonly used by pharmacy benefit managers. The overarching effects that the ACA will have on the U.S. healthcare system will be examined. This paper also analyzes how these changes could lead to an increase in access to care barriers for

patients requiring medication. Expected ramifications for both the newly and currently insured and potential solutions that could alleviate these issues will also be discussed. PBMs and control utilization tools The increasing usage and administrative costs associated with the management and payment of prescription drugs has led to health plans in the United States “carving out” this section of benefits to pharmacy benefit managers (PBMs). PBMs negotiate drug prices with both the pharmaceutical industry and pharmacies and act as the middleman between the payer and the rest of the health care system. PBMs utilize formularies to encourage the usage of medications that have been proven to be safe, effective and affordable.2–4 Table 1 illustrates four common utilization control and formulary exception features that patients have to directly deal with when they are getting prescriptions dispensed. There is evidence that these formulary features are effective at controlling drug spending, ensuring safe usage of medications, and shifting prescribing patterns toward the usage of preferred medications, especially those in the elderly and chronic disease population.2–4,6 Patient issues with control utilization tools Although the utilization control techniques used by PBMs have good intentions and attempt to help patients, they come with unintentional barriers to access of care.6–9 The primary argument against the prior authorization process is that the process not only requires the involvement of the PBM, pharmacy, and prescriber but also takes

Table 1 Examples of four common utilization control measures used by United States PBMs2–5 Type of utilization control measure

Prescriber contact

Length of process

Notes

Prior authorization

Yes

Step therapy

Dependent on patient history

Requires approval of PBM before medication is covered Requires attempt of preferred therapy

Tiered copayment

No

Ranges from instant to a few business days (more common) Usually instant, dependent on need of prescriber contact Instant

Quantity limits

Yes, if change in directions required

Dependent on responsiveness of prescriber

Determines cost sharing responsibility of patient Sets day supply and medication quantity restrictions

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time to complete, often several days. It has been estimated that prior authorizations have the ability to cost physicians $68,274 per year to deal with the process.10 Almost 70% of physicians reported several days as a typical wait time for prior authorization to be completed with 10% stating over a week as the length of the time they normally have to wait.10 Prior authorization has also been associated with a high “walk-away” rate. It has been estimated that almost 40% of prescriptions requiring a prior authorization fail to reach the patient and are instead abandoned.10–12 The dynamic nature of a drug formulary may have a negative impact on patients. Switching a drug from formulary status to requiring a prior authorization has the potential to lead to both an unexpected discontinuation/interruption of therapy or forced therapeutic switching. Patients may experience adverse effects, an increase in cost sharing responsibility, or a lesser therapeutic benefit from a forced switched in medication.2,3,7 This also opens the door for additional medical costs to incur as prescribers may have to be contacted to issue prescriptions for the new preferred drug.9 Increases in health care usage could also be seen while the patient adjusts to the new medication. Patients may also be less likely to use drug therapy or even discontinue necessary medications, due to the cost sharing responsibilities set in place by tiered copay levels. In these circumstances these policies present patients with a major access to care barrier, potentially leading to an increase in downstream medical costs and further usage of health care.7–9,13–17 Primary care physician shortage Another related factor to consider is that the U.S. currently is experiencing a physician shortage and will need an additional 52,000 primary care physicians to keep up with its population growth, aging population and insurance expansion.16 The recommended change in dose or medication specified by the insurance company may require additional physician and patient interaction. This interaction could be delayed by lack of appointment openings at the physician office or by an inability to reach either party. Similarly, patients experiencing adverse effects from medications may be impacted by the lack of physician availability.16,17

Methods A logic model was created to represent and summarize the major assumptions underlying the

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ACA (Fig. 1). A logic model can be viewed as a “road-map” of a program. It is a visual representation of how a program is intended to work and highlights what steps need to occur in order for the program to meet its expected goals. The inputs featured in the model are specific parts of the ACA that contribute to the funding of its implementation, will become parts of the United States healthcare system, or are areas of focus of the ACA. Inputs are found in the left most column of the model. Outputs of the model included reactionary changes that occurred in the U.S. healthcare system due to the inputs and the ACA. Outputs can be located in the middle column of the logic model. The outputs feed into the outcome portion of the logic model, which are divided into short, medium and long term. Outcomes are found in the third column of the logic model and included continued effects on the U.S. healthcare system that were a result from the outputs portion of the logic model. Outcomes of the implementation of the ACA are based on peer-reviewed and gray literature commentary related to health care reform and the ACA. A literature search was performed using the keywords: affordable care act, health care reform, health care issues, prescription drug coverage. Databases searched included PubMed and ScienceDirect. Other sources included the Center of Medicare and Medicaid Services, professional organization literature, national insurer and health policy organizations’ health care reform reviews and forecasts (e.g. Kaiser Family Foundation, Avalere, as well as other gray literature commentary on the ACA). Articles reviewed ranged from analysis of past health care legislation, government and professional organization statements regarding language of the ACA, and projected effects of the ACA as forecasted by health insurance companies and U.S. healthcare related professional journals. A wide range of materials was used to formulate the logic model in order to get the viewpoints of all affected stakeholders, some of which might not be present in primary literature. Predictions of effects of the ACA were dependent on a combination of several external factors: people elect to either enroll, if qualified, in Medicaid plans or purchase insurance plans from the insurance exchange; PBMs continue to use utilization control techniques in the same capacity; PBMs redesign their formularies within the restraints of the ACA, and the demand for health care will be largely based on affordability rather than the benefits offered. Other future health care factors that affect the model include: drug costs and spending being

462 Ung & Mullins / Research in Social and Administrative Pharmacy 11 (2015) 459–467 Fig. 1. Logic model representation of the Affordable Care Act. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article).

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influenced by brand patents expiring as well as the development of drugs such as “specialty drugs”; usage of health care by the newly insured; the effectiveness of treatment in prevention of disease and downstream usage of health care. The ACA will affect the United States healthcare system in a number of different ways. Some of its effects will be seen immediately while other effects will not be seen until areas of the ACA have been a working part of the U.S. healthcare system for a couple of years. The outcomes that are expected by the ACA in this model do not follow a linear progression. Some of these outcomes are related to one another and compound medium and long term outcomes. The outcomes visualized are also not equally distributed within the U.S. population. Some outcomes may affect the U.S. healthcare system to a greater degree than others. Desired outcomes of the ACA are highlighted in green, expected but unintended consequences of the law are in yellow, and undesirable outcomes are in blue. Results Increased formulary coverage One component of the ACA that directly affects formulary design lies in the “Essential Health Benefits (EHB) Rule.” The EHB rule states that for individual, small group, and other non-grandfathered insurance plan prescription drug coverage “at least the greater of (1) One drug in every USP category and class; or (2) the same number of drugs in each category and class as the EHB-benchmark plan” must be covered.18 This law marks the first time the United States federal government has mandated formulary requirements outside of Medicare Part D sponsors.19 The EHB rule will force pharmacy benefit managers to model and mimic their exchange formularies after the state selected benchmark plan.18 The intended effect of the rule is clear – to increase access and affordability of prescription drugs for those who need them.19,20 Greater plan variability Plans offered on the exchange come in five different levels, based on the average percentage of cost of covered benefits that the insurance plan will pay for. These levels range from 60% (Bronze) to 90% (Platinum). A catastrophic plan will also be made available to people under the age of 30 or whose percentage of income spent on health insurance would exceed 8%. Each state

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participating in the exchange marketplace will select their benchmark plan.18 Patients will see differences in the type of coverage seen on the marketplace depending on their state of residence. Increased government financial assistance The ACA does offer financial assistance for prescription drugs and health care. Medicare Part D beneficiaries are among those that see the most assistance. In the past, Medicare Part D enrollees were responsible for a deductible for their prescription drugs. After this deductible would be met, cost sharing with the Medicare Part D plan would be started until a yearly coverage limit is reached. After this limit, the patient would be responsible for all prescription drug costs until reaching a catastrophic coverage limit. The gap between the initial limit and the catastrophic limit is referred to as the “donut” hole. Provisions in the ACA will gradually decrease the amount of patient cost-sharing responsibility in the donut hole from 100% to being completely eliminated in 2020. There will also be negotiated discounts for branded medications while in the coverage gap. Individuals and families, whose income falls between 133% up to 400% of the poverty level, will receive subsidies from the government to purchase insurance plans from the exchange. Those whose income is between 133 and 250% of the poverty line will only be responsible for premiums totaling from 3 to 8.05% of their income while those who earn 300–400% of the poverty level will have a premium spending cap of 9.5%.18 Accountable Care Organizations/Health Information Technology ACOs are organizations which hold the financial risk associated with treating a population and the outcomes associated with it. They emphasize accountability within its many branches of health care including, but not limited to; physicians, institutions, mental health, and long term care. The ACA gives United States healthcare providers incentives to work with others to increase the quality of care and provide resources and tools to build their own ACO structures. Because the ACO and payer hold the financial risk, there is a greater incentive to measure quality of care and to examine both the short- and long-term care of the population. ACOs had gained popularity even before the introduction of the ACA with Kaiser and CareFirst being two current examples.19,21,22 It is believed that interprofessional collaborations,

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such as an ACO, will help alleviate the primary care physician shortage by increasing the efficiency of health care delivery.20,23 Having this ability to coordinate care among different health care areas is thought to positively affect patient outcomes.20,23 The need for greater usage of technology in the U.S. healthcare system is also addressed in the ACA. The ACA provides incentives for the usage of health information technology (HIT) as well as penalties for those who are not utilizing such tools.18 Electronic prescribing and electronic health records are two examples of HIT technology that have increased efficiency and communication between providers in the U.S.11,24 The use of HIT provides a way for physicians and other members of the health care team, to better manage their patients.20,23

Discussion Excess spending Although government mandated formulary requirements aim to increase patient access to medication, it is not universally accepted that these requirements are the best way to control prescription drug prices.9,13 The Academy of Managed Care Pharmacy (AMCP), which has a large constituent of members who are part of pharmacy benefit design, strongly opposes this part of the EHB rule. The association argues that this U.S. government mandate will lead to a level of unnecessary coverage of drugs which ultimately increases the costs to all stakeholders. This excess coverage was seen with the implementation of Medicare Part D.13,20 Plans created to serve the Medicare Part D population are forced to cover “all or substantially all drugs in the antidepressant, antipsychotic, and anticonvulsant classes, immunosuppressant (for prophylaxis of organ transplant rejection), antiretroviral, and antineoplastic” classes. It has been estimated that this government mandate has led and will lead to almost $4 billion in extra spending from 2010– 2018.1,25,26 The tradeoff between greater formulary coverage versus controlling drug spending and insurance costs is open to debate but the Medicare Part D does illustrate that mandated coverage has the potential to lead to a level of excess spending.25,27 AMCP also takes the stance that formulary design should be allowed flexibility in order to take an evidenced-based approach. Part of their argument is based on the issue of

formulary updates.20 The persons with the responsibility of creating and maintaining a drug formulary have to take into account newly approved drugs, newly FDA-approved usages of drugs currently on the market, and additional information about drug efficacy and safety that may arise. All this new information may change previous decisions about a drug’s position on a formulary. Required coverage of drugs may lead to outdated and inferior decisions about drug inclusion on a formulary and lead to both excess cost and suboptimal patient outcomes.13,25 Additionally, the benchmark plan may have been designed for the specific needs of the population it will serve. The priority of these medical needs may change in different areas of the state and a different formulary design may be more cost effective for other regions. This forecasted excess spending coincides with the belief of gray literature commentary, which predicts that the ACA will lead to short term increases in both premiums and deductibles in U.S. insurance plans.17,28 The ACA aims to curb rising prescription drug costs by requiring insurance plans to cover more drugs.18 This is a temporary fix that does not address the root of the problem. Mandating coverage for certain drugs or drug classes covered actually erodes the leverage that PBMs have to negotiate prices with drug manufacturers. Taking this power away not only opens the door for excess drug spending but allows drug prices to increase without much consequence.20 The goal should be to emphasize the quality of the product being developed and used and to control the costs of medication by limiting coverage and access to medication to drugs that are backed by scientific evidence illustrating their cost effectiveness. Additional concerns with utilization management tools The ACA will extend prescription drug coverage to many patients who have not previously had access to insurance for pharmaceuticals. However, the issues and problems resulting from the control utilization tools have not been addressed by the ACA. These will only grow in number as the number of insured people rise. More insured patients equates to more patients encountering a situation where prior authorization is required. As evidenced by the current high “walk-away” rate associated with prior authorization, a large portion of these patients will fail to start their newly prescribed medication therapy.6,8,12 Patients failing

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to start their medication may fail to adhere to their physician’s advice and see their condition worsen. Attempts to schedule more frequent or urgent visits may not be a feasible option due to the physician workload, which may be exacerbated due to an influx of new patients who now have insurance due to the ACA.16,17 An interesting note, a survey revealed that 31% of physicians indicated that they were unwilling to accept new Medicaid patients.29 We may see patients with insurance unable to easily access primary care options and instead turn to emergency rooms for medical needs that are not urgent in nature.11 This increase use of emergency rooms crowds waiting rooms and is a more expensive alternative.11 It is largely unknown how many individuals will use the insurance exchange to purchase insurance for their current health conditions. Forecasting the amount of health care that this newly insured population will utilize is a difficult task for insurers. An increase in health care usage due to the addition of new insurance benefits and a newly insured population could lead to increases in the cost of health care.28 Similarly, an increase in the demand of health care usage will further strain shortages in health care, such as the previously noted primary care physician gap.16 In addition to the newly insured, those currently with insurance may also be negatively affected by the ACA. As previously mentioned, the utilization control techniques present in drug benefit plans are far from perfect. There are many cases where patients either fail to or see a delay in the initiation of their drug therapy or experience an unexpected interruption of therapy.2,3,6,8,10,12,14,28 The ACA does not prevent PBMs from using such techniques to address the problems seen with these methods, leaving patients to continue to deal with access to care barriers. Patients not selecting appropriate plans The demand for health care in the U.S. typically has been centered on cost, as evidenced by the usage of “Affordable” in the ACA. Parts of the ACA, such as the EHB, mandate covered services. The implementation of the medical loss ratio threshold is also forecasted to increase the amount of spending by health care plans when providing actual health care, which will potentially reduce their profit margin.18,28,30 To remain competitive, pharmacy benefit managers will have to redesign their drug benefits to appeal to consumers who may put a high value on

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affordability.28 Utilization control techniques, which have been shown to control drug spending, will undoubtedly remain in use. The government formulary mandates present in the ACA will require plans to meet the benchmark plan formulary, but PBMs will be able to use utilization control techniques to satisfy these requirements.18 The ACA states that insurance plans must provide an easy to read explanation of benefits but patients may still fail to understand the complexity that exists in a drug formulary.14,28 Many patients may select the plan with the least expensive premium in efforts to save money, but this same plan may not be the most medically appropriate.31 The plan with the less expensive premium may have a higher cost sharing responsibility in the form of a copay or deductible or even lack coverage for the patient’s current medication. The plan that most suits the patient’s medical needs might have a higher premium but also a lower copay or deductible. Additionally, patients could encounter problems when choosing their insurance plan and be unable to find the cheapest plan that is appropriate for their medical needs.31 Short-term increases in the cost of insurance may be seen for some groups of people that do not qualify for government assistance. The hope is, however, that this initial increase will lead to a greater downstream decrease on the amount of spending on treatment, as prevention of disease continues to be emphasized.19 The ACA does take a step forward in providing access to insurance and assisting with cost-sharing responsibility but patients will still face similar problems at the pharmacy counter. Increased HIT and interprofessional collaboration The control utilization techniques and formulary features used by PBMs are far from perfect. Interruption, delay of initiation of drug therapy, and administrative burden are a few complaints of these techniques.2,6,8,10,12,13 Evaluating the current usage of such methods through additional costeffectiveness studies and eliminating the unnecessary usage of these utilization control tools, will help address patient complaints. The prior authorization process in particular is a tool that is far from being used at its greatest efficiency. A trial utilizing an instant approval process (IAP) has illustrated the potential to alleviate traditional PA burdens.11 The instant approval process was different than normal PA procedures in that it allowed prescribers to write PA criteria directly on

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the prescription form or use a form that was faxed from the prescriber office to the dispensing pharmacy. IAP led to a decrease in administrative burden for physicians, helped patient outcomes, and increase in satisfaction by the pharmacist.11 Prior authorization currently requires paperwork to be filled out, faxing and phone calls between physicians, pharmacists, and insurance companies, but fails to effectively use current technology, and appears outdated. The time a patient has to wait for the prior authorization approval process can be cut down by implementing modern technology. Continued usage and infusion of HIT into the health care system such as Instant Approval Process could further eliminate delay or interruption of therapy.11,32 Traditionally, physicians work in separate environments than pharmacists, dentists, surgeons, and even physicians of other specialties. In many cases, there is a lack of communication between prescriber and a pharmacist or a primary care physician and a specialty physician. This disconnects leaves the patient lost in the middle, opening the door for duplication or conflicting treatment plans, delay of treatment, and excess cost and time spent running between offices.9 In United States pharmacies it is a common occurrence for a pharmacist to contact a doctor to clarify the handwriting of the prescription, if the physician is aware of a potential drug interaction, or to initiate a prior authorization or steptherapy process. In some instances, physicians are unable to be reached immediately by telephone or fax, leaving the patient to wait. One possible way to combat this communication problem is a stronger emphasis and supported development of Accountable Care Organizations (ACOs), highlighted in the ACA.18,22 In these models the coordination of care of prescriber and pharmacist drastically improves the efficiency of communication between both parties. Prior authorization and other formulary management tools are easily accessible to prescribers, cutting down on the time patients would traditionally have to wait for formulary exception process to occur. ACOs are an innovative way to deliver health care. They put pharmacists, nurses, and other members of the health care team in a position to be more involved in the care of a patient.23 It is thought that the primary care physician shortage in the United States is overestimated and instead could be alleviated by increasing the efficiency of the U.S. healthcare system.23 A future idea for health care reform would be the expansion of duties for pharmacists, nurse practitioners, and other health care professionals.

There has been recent legislation passed in California that grants licensed pharmacists the ability to perform and be reimbursed for specified patient care tasks and recognizes pharmacists as “health care providers.” Such evolution in pharmacy and other health care avenues is a way we can decrease the need of physicians for primary care.20 The continued growth, improvement and prevalence of interprofessional collaboration within ACOs and other health care delivery models is a way to decrease current access to care barriers present in the U.S. healthcare system.18,19,22 Conclusion The ACA takes several strides in fixing some of the problems that currently exist in the United States healthcare system. The number of uninsured people in the U.S. country will decrease, patients will receive greater coverage benefits and the quality of care they are receiving will improve.19 Current problems with the U.S. healthcare system such as access to care barriers caused by formulary utilization control techniques and primary care physician shortages will continue to exist if more changes are not put into place or emphasized. Greater coverage by insurance plans also opens the door for increased spending on healthcare. The success of the ACA and future health reform could be influenced by increasing the efficiency of communication between different parts of the health care system. Effective collaboration between physicians, pharmacists, etc. combined with increasing the usage of health information technology are two things going forward that will play factors in health care reform. References 1. Moffit RE, Senger A. Medicare’s Demographic Challengedand the Urgent Need for Reform. The Heritage Foundation; 2013. Report No.: 2778. 2. Academy of Managed Care PharmacyShoemaker SJ, Pozniak A, Subramanian R, Mauch D. Effect of 6 managed care pharmacy tools: a review of the literature. J Manag Care Pharm 2010 Jul;16(6 suppl l):S3–S20. 3. Goldman DP, Joyce GF, Zheng Y. Prescription drug cost sharing: associations with medication and medical utilization and spending and health. J Am Med Assoc 2007 Jul 4;298(1):61–69. 4. Miller DP, Furberg CD, Small RH, et al. Controlling prescription drug expenditures: a report of success. Am J Manag Care 2007 Aug;13(8):473–480. 5. Kelly AM, Cronin P, Carlos RC. Introduction to value-based insurance design. J Am Coll Radiol 2008 Nov;5(11):1118–1124.

Ung & Mullins / Research in Social and Administrative Pharmacy 11 (2015) 459–467 6. Suehs BT, Louder A, Udall M, Cappelleri JC, Joshi AV, Patel NC. Impact of a pregabalin step therapy policy among medicare advantage beneficiaries. Pain Pract; 2013 May 23:419–426. 7. Cote BR, Petersen EA. Impact of therapeutic switching in long-term care. Am J Manag Care 2008 Nov; 14(11 suppll):SP23–SP28. 8. Zhang Y, Adams AS, Ross-Degnan D, Zhang F, Soumerai SB. Effects of prior authorization on medication discontinuation among medicaid beneficiaries with bipolar disorder. Psychiatr Serv 2009 Apr;60(4): 520–527. 9. Raper JL, Willig JH, Lin HY, et al. Uncompensated medical provider costs associated with prior authorization for prescription medications in an HIV clinic. Clin Infect Dis 2010 Sep 15;51(6):718–724. 10. Morley CP, Badolato DJ, Hickner J, Epling JW. The impact of prior authorization requirements on primary care physicians’ offices: report of two parallel network studies. J Am Board Fam Med 2013 JanFeb;26(1):93–95. 11. Jacobson Vann JC, Christofferson S, Humble CG, Wegner SE, Feaganes JR, Trygstad TK. Pharmacist and physician satisfaction and rates of switching to preferred medications associated with an instant prior authorization program for proton pump inhibitors in the north carolina medicaid program. J Manag Care Pharm 2010 May;16(4):250–263. 12. Bergeson JG, Worley K, Louder A, Ward M, Graham J. Retrospective database analysis of the impact of prior authorization for type 2 diabetes medications on health care costs in a medicare advantage prescription drug plan population. J Manag Care Pharm 2013 Jun;19(5):374–384. 13. Boucher BA. Formulary decisions: then and now. Pharmacotherapy 2010 Jun;30(6 Pt 2):35S–41S. 14. Polinski JM, Kilabuk E, Schneeweiss S, Brennan T, Shrank WH. Changes in drug use and out-of-pocket costs associated with medicare part D implementation: a systematic review. J Am Geriatr Soc 2010 Sep;58(9):1764–1779. 15. Gilmer T. Costs of chronic disease management for newly insured adults. Med Care 2011 Sep;49(9): e22–e27. 16. Petterson SM, Liaw WR, Phillips RL Jr, Rabin DL, Meyers DS, Bazemore AW. Projecting US primary care physician workforce needs: 2010-2025. Ann Fam Med 2012 Nov-Dec;10(6):503–509. 17. Goodson JD. Patient protection and Affordable Care Act: promise and peril for primary care. Ann Intern Med 2010;172(11):742–744.

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18. Protection P, Act AC. Patient Protection and Affordable Care Act. Public Law; 2010. p. 111–148. 19. Lofton JC. APhA Pharmacy Law Matters 2010: Focus on Selected Provisions of the Affordable Care Act. Pharmacy Today; December 2010. p. 72–83. 20. Auerbach DI, Chen PG, Friedberg MW, et al. New Approaches for Delivering Primary Care Could Reduce Predicted Physician Shortage; 2013. 21. Brown LM. Emerging opportunities for pharmacists to improve health care for the poor and underserved. J Health Care Poor Underserved 2013 Feb; 24(1 suppl l):6–14. 22. Burke T. Accountable care organizations. Public Health Rep 2011 Nov-Dec;126(6):875–878. 23. Green LV, Savin S, Lu Y. Primary care physician shortages could be eliminated through use of teams, nonphysicians, and electronic communication. Health Aff (Millwood) 2013 Jan;32(1):11–19. 24. Shekelle PG, Morton SC, Keeler EB. Costs and benefits of health information technology. Evid Rep Technol Assess (Full Rep) 2006 Apr;(132):1–71. 25. Berwick DM, Hackbarth AD. Eliminating waste in US health care. J Am Med Assoc 2012;307(14): 1513–1516. 26. Borger C, Smith S, Truffer C, et al. Health spending projections through 2015: changes on the horizon. Health Aff (Millwood) 2006 Mar-Apr;25(2):w61–73. 27. Zhang Y, Donohue JM, Lave JR, O’Donnell G, Newhouse JP. The effect of medicare part D on drug and medical spending. N Engl J Med 2009; 361(1):52–61. 28. [Internet]Why premiums will change for people who now have Nongroup Insurance; 2013, Feb 6. Available from: Why premiums will change for people who now have Nongroup insurance. 29. Decker SL. In 2011 nearly one-third of physicians said they would not accept new medicaid patients, but rising fees may help. Health Aff (Millwood) 2012 Aug;31(8):1673–1679. 30. Chen T, Cost P, Gaitonde P. The impact of patient protection and affordable care act regulations on drug manufacturers’ medicaid market segment profitability. Value Health 2013 May 01;16(3):A8. 31. Zhou C, Zhang Y. The vast majority of medicare part D beneficiaries still Don’t choose the cheapest plans that meet their medication needs. Health Aff 2012, October 01;31(10):2259–2265. 32. Wu S, Chaudhry B, Wang J, et al. Systematic review: Impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med 2006;144(10):742–752.

The Affordable Care Act, health care reform, prescription drug formularies and utilization management tools.

The U.S. Patient Protection and Affordable Care Act (hence, Affordable Care Act, or ACA) was signed into law on March 23, 2010. Goals of the ACA inclu...
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