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Which drugs should health plans cover?

SEATTLE--With the cost of prescription drugs rising faster than any other part of health care, more insurers and health systems have begun adopting restrictive policies for coverage of newer drugs. How can consumers and health care organizations be sure that such policies don't lean too far in either direction--either restricting necessary treatment or wasting consumers' premiums on expensive medicines that offer no real advantage?

These issues are addressed by experts from Group Health in an article in the October 2005 issue of the Journal of General Internal Medicine. The piece presents five principles that organizations can use to protect patients when they compare the benefits, risks, and costs of drugs to include in their "formularies," the lists of drugs approved for coverage.

"Manufacturers of new drugs make a range of claims about clinical benefits, differences in cost, and cost effectiveness," said Greg Simon, MD, MPH, a Group Health psychiatrist and researcher who is the lead author of the article. "Decision makers need some principles for sorting through those claims." While other groups have established broad principles for addressing the problem, the Group Health authors offer "more specific rules for identifying the right questions and the most important evidence," Simon explained.

In addition to Simon, co-authors on this paper include Bruce Psaty, MD, PhD, a Center for Health Studies senior investigator and University of Washington professor of medicine and epidemiology who is also a member of Institute of Medicine Committee on the Assessment of the U.S. Drug Safety System; Group Health physician Marc Mora, MD, former chair of the committee that establishes formulary policies for Group Health; and Group Health pharmacist Jennifer Berg Hrachovec, PharmD, MPH.

The five principles, described in more detail below, are:

1. Give more weight to true experiments than to models or simulations, and carefully examine assum
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Contact: Joan DeClaire
declaire.j@ghc.org
206-287-2653
Group Health Cooperative Center for Health Studies
28-Oct-2005


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