Department of Clinical Pharmacy, University of California San Francisco, San Francisco, CA, USA.
Department of Medicine, Health Policy and Economics, University of California San Francisco, 3333 California Street, Suite 420, Box 0613, San Francisco, CA, 94143, USA.
Appl Health Econ Health Policy. 2019 Apr;17(2):231-242. doi: 10.1007/s40258-018-0442-2.
Pricing drugs in the California Workers' Compensation System (CAWCS) has become more difficult as there are increasingly fewer drugs listed in the Medi-Cal primary fee schedule, which is used as the source for CAWCS drug prices. This presents a challenge of providing timely and accurate CAWCS reimbursement. The objectives of this study are (1) to explore any trends in physician-dispensed drug prices; (2) to compare the proportion of drugs with and without a price and to determine the financial implications of repricing CAWCS physician-dispensed drugs with five alternative pricing benchmarks; and (3) to offer recommendations for the pricing benchmark to maximize pricing coverage and to remain budget neutral.
We evaluated physician-dispensed drugs at the transaction level, reimbursed in the CAWCS. Frequency, reimbursement rate, and total and average paid costs were reported. We matched each claim line in the CAWCS to the corresponding unit price of an alternative price benchmark including average wholesale price, wholesale acquisition cost, direct prices, national average drug acquisition cost, and Federal Upper Limit.
Average wholesale price provided prices for 99.9% of physician-dispensed drug claims, while Medi-Cal, the current primary physician-dispensed drug benchmark provided prices for a lower percentage (92.7%) of claims. The CAWCS prices were equivalent to 49% of the average wholesale price, 95.5% of Medi-Cal, 126.7% of the wholesale acquisition cost, 266% of the Federal Upper Limit, 64.4% of direct prices, and 197% of national average drug acquisition cost-estimated prices.
The CAWCS current Medi-Cal pricing for physician-dispensed drugs is better than all alternatives in terms of price availability, transparency, and budget neutrality, but pricing availability may decrease over time as Medi-Cal moves to managed care. National average drug acquisition cost is the next best alternative, but it requires combinations of pricing benchmarks to maximize its price availability.
随着 Medi-Cal 初级费用表中列出的药物越来越少，加利福尼亚工人补偿系统 (CAWCS) 的药物定价变得更加困难，该表被用作 CAWCS 药物价格的来源。这给提供及时和准确的 CAWCS 报销带来了挑战。本研究的目的是：(1) 探讨医生配药药物价格的任何趋势；(2) 比较有价格和无价格药物的比例，并确定使用五种替代定价基准重新定价 CAWCS 医生配药药物的财务影响；(3) 为定价基准提供建议，以最大限度地提高定价覆盖范围并保持预算中性。
我们在 CAWCS 中按交易水平评估了医生配药的药物。报告了频率、报销率以及总支付和平均支付成本。我们将 CAWCS 中的每条索赔行与替代价格基准的相应单价进行匹配，包括平均批发价格、批发采购成本、直接价格、国家平均药物采购成本和联邦上限。
平均批发价格为 99.9%的医生配药药物索赔提供了价格，而 Medi-Cal（当前的主要医生配药药物基准）提供的价格则较低（92.7%的索赔）。CAWCS 的价格相当于平均批发价格的 49%、Medi-Cal 的 95.5%、批发采购成本的 126.7%、联邦上限的 266%、直接价格的 64.4%和国家平均药物采购成本估算价格的 197%。
从价格可用性、透明度和预算中性的角度来看，CAWCS 当前用于医生配药药物的 Medi-Cal 定价优于所有替代方案，但随着 Medi-Cal 转向管理式医疗，定价可用性可能会随着时间的推移而下降。国家平均药物采购成本是下一个最佳选择，但需要组合使用定价基准以最大限度地提高其价格可用性。
