Group practice strategies to manage pharmaceutical cost in an HMO network

Objective: To evaluate the prevalence of various pharmaceutical cost management strategies used by group practices within a managed care network and their relationship to drug costs among enrollees. Strategies studied: Care management (gatekeeping, practice profiling, practice guidelines, case management), techniques for maintaining clinic medication records, and policies regulating physician interaction with pharmaceutical sales representatives (PSRs). Study design: Cross-sectional survey of primary care group practice organizations (n = 103) affiliated with Blue Cross Blue Shield of Minnesota in early 1996. Methods: Multivariate linear regression analysis was performed on corresponding claims data for members continuously enrolled in these practices from January 1 to December 31, 1995 (n = 76,387), using the patient as the unit of analysis. Results: Substantial variation in strategy prevalence was observed; this variation was thought to influence pharmaceutical costs. Seventy-six percent of practices had medication lists in outpatient medical records, 53% had policies limiting pharmaceutical detailing, and 44% had patients assigned to primary care gatekeepers; however, only 10% used outpatient nurse case managers. Use of outpatient nurse case managers (P < .010), primary care physician gatekeeping (P < .002), policies to control pharmaceutical detailing (P < .001), and medication lists and outpatient charts (P < .001) was found to be independently associated with lower pharmaceutical expenditures. Significant colinearity was found between group size and the strategies studied. Conclusions: Significantly lower pharmaceutical costs per member per year were observed in the groups reporting primary care gatekeeping, outpatient medication records, outpatient case managers, and policies regarding physician interactions with PSRs.