Baldini Christopher G, Culley Eric J
Clinical Pharmacy Services, Highmark Blue Cross Blue Shield, 120 Fifth Avenue, Suite 1812, Pittsburgh, PA 15222, USA.
J Manag Care Pharm. 2011 Jan-Feb;17(1):51-9. doi: 10.18553/jmcp.2011.17.1.51.
A large managed care organization (MCO) in western Pennsylvania initiated a Medical Injectable Drug (MID) program in 2002 that transferred a specific subset of specialty drugs from physician reimbursement under the traditional "buy-and-bill" model in the medical benefit to MCO purchase from a specialty pharmacy provider (SPP) that supplied physician offices with the MIDs. The MID program was initiated with 4 drugs in 2002 (palivizumab and 3 hyaluronate products/derivatives) growing to more than 50 drugs by 2007-2008.
To (a) describe the MID program as a method to manage the cost and delivery of this subset of specialty drugs, and (b) estimate the MID program cost savings in 2007 and 2008 in an MCO with approximately 4.6 million members.
Cost savings generated by the MID program were calculated by comparing the total actual expenditure (plan cost plus member cost) on medications included in the MID program for calendar years 2007 and 2008 with the total estimated expenditure that would have been paid to physicians during the same time period for the same medication if reimbursement had been made using HCPCS (J code) billing under the physician "buy-and-bill" reimbursement rates.
For the approximately 50 drugs in the MID program in 2007 and 2008, the drug cost savings in 2007 were estimated to be $15.5 million (18.2%) or $290 per claim ($0.28 per member per month [PMPM]) and about $13 million (12.7%) or $201 per claim ($0.23 PMPM) in 2008. Although 28% of MID claims continued to be billed by physicians using J codes in 2007 and 22% in 2008, all claims for MIDs were limited to the SPP reimbursement rates.
This MID program was associated with health plan cost savings of approximately $28.5 million over 2 years, achieved by the transfer of about 50 physician-administered injectable pharmaceuticals from reimbursement to physicians to reimbursement to a single SPP and payment of physician claims for MIDs at the SPP reimbursement rates.
宾夕法尼亚州西部的一家大型管理式医疗组织（MCO）于2002年启动了一项医用注射药物（MID）计划，该计划将特定的专科药物子集从传统“购买并计费”模式下的医生报销（医保福利范畴）转移至由专科药房供应商（SPP）向MCO供应，再由SPP向医生办公室提供这些MID药物。2002年该MID计划起始时有4种药物（帕利珠单抗和3种透明质酸盐产品/衍生物），到2007 - 2008年增加到50多种药物。
（a）将MID计划描述为管理这一专科药物子集成本和供应的一种方法，（b）估算2007年和2008年在一个拥有约460万会员的MCO中MID计划节省的成本。
通过比较2007年和2008年MID计划所涵盖药物的实际总支出（计划成本加会员成本）与如果按照医生“购买并计费”报销费率使用医疗保健通用程序编码系统（HCPCS，J编码）计费在同一时期向医生支付的相同药物的估计总支出，来计算MID计划产生的成本节省。
对于2007年和2008年MID计划中的约50种药物，2007年药物成本节省估计为1550万美元（18.2%），即每项索赔节省290美元（每月每位会员节省0.28美元[PMPM]），2008年约为1300万美元（12.7%），即每项索赔节省201美元（0.23美元PMPM）。尽管2007年28%的MID索赔仍由医生使用J编码计费，2008年这一比例为
