Journal of managed care & specialty pharmacy最新文献

{"title":"Patient out-of-pocket costs and rheumatology biosimilar competition.","authors":"Victoria W Dayer, Ryan N Hansen, Joshua Roth, Mireia Jofre-Bonet, Sean D Sullivan","doi":"10.18553/jmcp.2026.32.5.563","DOIUrl":"10.18553/jmcp.2026.32.5.563","url":null,"abstract":"<p><strong>Background: </strong>Despite demonstrated savings from biosimilars, evidence examining savings experienced by patients is mixed, especially in the commercially insured population. Reference product prices typically decrease after biosimilars enter the market, so documented savings from existing studies cannot causally conclude that biosimilar competition itself has led to overall patient out-of-pocket (OOP) savings for both reference products and biosimilars as prices come down.</p><p><strong>Objective: </strong>To assess the impact of biosimilar competition on patient OOP costs for rheumatology biologics.</p><p><strong>Methods: </strong>We used claims from the Merative MarketScan Commercial Database from January 1, 2011, through December 31, 2023, to conduct a Callaway and Sant'Anna difference-in-differences analysis of patient OOP costs before and after biosimilar competition. Patients were included if they had at least 2 drug claims for a single qualifying drug in each year of inclusion and had continuous enrollment for the whole year. We included infliximab, rituximab, and adalimumab as the drug groups of interest, as they are rheumatology biologics with biosimilars available. The control group consisted of drugs with similar mechanisms of action and place in therapy based on US Food and Drug Administration-approved indications and clinical guidelines to the drugs of interest that did not have biosimilars available during the study period. The exposure in the analysis was biosimilar competition (availability of biosimilars), and the outcome was biologic-related OOP costs.</p><p><strong>Results: </strong>We observed significant patient OOP savings because of biosimilar competition, with an average annual OOP difference of -$1,133.90 (95% CI -$1,200.35 to -$1,067.45) in the infliximab group, -$1,437.63 (95% CI -$1,549.98 to -$1,325.28) in the rituximab group, and -$375.01 (95% CI -$539.57 to -$210.45) in the adalimumab group compared with the control group during the study period (January 1, 2011, through December 31, 2023). In the adalimumab group, there were no patient savings in a scenario analysis that omitted the year before biosimilar entry to account for anticipatory price increases, and the results in that group are preliminary because there was only 1 year of data in the postperiod. When assessing treatment effect by duration of exposure, we observed increasing savings over time the longer biosimilars were available for infliximab and rituximab.</p><p><strong>Conclusions: </strong>Biosimilar competition resulted in decreased OOP costs in patients using infliximab and rituximab biologics, using similar biologics without biosimilars available as a control group. Preliminary results for adalimumab are inconclusive. The results indicate that the availability of infliximab and rituximab biosimilars has led to significant savings for patients, with savings increasing the longer biosimilars remain on the market. Because of these de","PeriodicalId":16170,"journal":{"name":"Journal of managed care & specialty pharmacy","volume":"32 5","pages":"563-573"},"PeriodicalIF":3.3,"publicationDate":"2026-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13121773/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147774118","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Cost-effectiveness analysis of treatment strategies initiating with second-generation antipsychotic long-acting injectables in patients with schizophrenia in the United States.","authors":"Cindy M Chan, Tushita Mayanil, K N Roy Chengappa, Kangho Suh","doi":"10.18553/jmcp.2026.32.5.596","DOIUrl":"10.18553/jmcp.2026.32.5.596","url":null,"abstract":"<p><strong>Background: </strong>Schizophrenia is associated with high treatment nonadherence and economic burden in the United States. Long-acting injectable (LAI) antipsychotics may improve adherence and reduce relapse risk, but comparative cost-effectiveness data of second-generation antipsychotic (SGA) LAIs in the United States remain limited.</p><p><strong>Objective: </strong>To compare the cost-effectiveness of treatment strategies initiating with 4 SGA LAIs, aripiprazole monohydrate, aripiprazole lauroxil, olanzapine pamoate, and risperidone, with the strategy initiating with monthly paliperidone palmitate in patients with schizophrenia from the US health care sector perspective.</p><p><strong>Methods: </strong>A Markov model with 90-day cycles was developed to simulate the progression of 40-year-old adults transitioning among stable treated, stable nontreated, and relapse health states and death over 5 years at a 3% discount rate. Patients transitioned to additional lines of therapy (another SGA LAI and then clozapine) after relapse or intolerance to side effects. Transition probabilities were derived from US claims-based observational studies, clinical trials, and meta-analyses. Health state utilities and disutilities due to extrapyramidal symptoms, weight gain, and diabetes from published literature were applied to age-adjusted utility of the US population.</p><p><strong>Results: </strong>Compared with the treatment strategy initiating with paliperidone (3.22 quality-adjusted life-years [QALYs]), treatment strategies initiating with the other SGA LAIs generated slightly lower to similar QALYs. Strategies initiating with aripiprazole monohydrate and risperidone were dominated by the paliperidone-initiating strategy. Strategies initiating with aripiprazole lauroxil and olanzapine resulted in lower total health care costs but lower QALYs, with incremental cost-effectiveness ratios of $242,477 and $2,887, respectively. Sensitivity analysis confirmed the robustness of these findings, with LAI drug costs and relapse probabilities being the most influential parameters.</p><p><strong>Conclusions: </strong>Over a 5-year horizon, the treatment strategy initiating with paliperidone emerged as a favorable LAI option, providing the highest QALY gains at comparable or lower costs than the other LAI-initiating strategies.</p>","PeriodicalId":16170,"journal":{"name":"Journal of managed care & specialty pharmacy","volume":"32 5","pages":"596-610"},"PeriodicalIF":3.3,"publicationDate":"2026-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13119491/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147774087","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The effectiveness of care coordination on medication adherence among high-need, high-cost commercially insured beneficiaries: A randomized controlled trial.","authors":"Rintu Saju, Jessica M Harwood, Chi-Hong Tseng, Tannaz Moin, Carol Mangione, O Kenrik Duru, Sae Takada, Stephen Onufrak","doi":"10.18553/jmcp.2026.32.5.540","DOIUrl":"10.18553/jmcp.2026.32.5.540","url":null,"abstract":"<p><strong>Background: </strong>High-need, high-cost (HNHC) beneficiaries experience life stressors that complicate their medication self-management. Care coordination programs may improve medication-taking behavior, including for chronic conditions that require daily medication adherence.</p><p><strong>Objective: </strong>To determine whether nurse-led care coordination is associated with improved adherence among an HNHC commercial population with a chronic condition.</p><p><strong>Methods: </strong>We analyzed data from a pragmatic, national randomized controlled trial of a comprehensive care coordination program conducted by a large national insurer and assessed its impacts on medication adherence in diabetes, atrial fibrillation, and hypothyroidism. We performed intention-to-treat (ITT) analyses (primary) and instrumental variable (IV) analyses (secondary) for HNHC beneficiaries from 2019 through 2022. Analyses compared treatment of control arms for metformin in diabetes (n = 3,602), statins in diabetes (n = 3,938), direct oral anticoagulants in atrial fibrillation (n = 326), and levothyroxine in hypothyroidism (n = 2,496). The primary adherence outcome was defined as proportion of days covered (PDC) greater than or equal to 80%, with continuous adherence measured as a secondary outcome. We used multivariate regression models to compare outcomes between arms. For the IV analyses, we used randomization status as the instrument. Covariates included age, sex, geographic location, plan type, and 18 comorbidity indicators. We also conducted sensitivity analyses limited to beneficiaries with baseline PDC less than 80%.</p><p><strong>Results: </strong>In the primary ITT analyses, we did not observe statistically significant differences between treatment and control arms in the percentage of beneficiaries with PDC greater than or equal to 80% for metformin (66% vs 68%, <i>P</i> = 0.22), statins (69% vs 70%, <i>P</i> = 0.55) or direct oral anticoagulants (71% vs 68%, <i>P</i> = 0.6). However, beneficiaries taking levothyroxine were more likely to have PDC greater than or equal to 80% than those assigned to control (77% vs 73%, <i>P</i> = 0.02). Similar results were observed in the secondary IV analyses. In the secondary ITT analyses examining adherence as a continuous outcome, we did not observe any differences between arms. Finally, in the sensitivity analyses limited to beneficiaries with baseline PDC less than 80%, we also found no adherence differences.</p><p><strong>Conclusions: </strong>We found that care coordination did not improve medication adherence in HNHC beneficiaries. Our results align with prior studies and emphasize the challenges of improving adherence within a complex HNHC beneficiary population.</p><p><strong>Trial registration: </strong>ClinicalTrials.gov NCT04415515.</p>","PeriodicalId":16170,"journal":{"name":"Journal of managed care & specialty pharmacy","volume":"32 5","pages":"540-550"},"PeriodicalIF":3.3,"publicationDate":"2026-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13119495/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147773723","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Compliance with the Veterans Health Administration's Pharmacy Benefit Management guidance for duration of clopidogrel following peripheral vascular interventions: a retrospective cohort study.","authors":"Sharon E Kim, Jennifer McCoy, Monique Boudreaux-Kelly, Franya Hutchins, Fran Cunningham, Shari Rogal, Edith Tzeng, Daniel E Hall, Carolyn T Thorpe, Katherine M Reitz","doi":"10.18553/jmcp.2026.32.5.613","DOIUrl":"10.18553/jmcp.2026.32.5.613","url":null,"abstract":"<p><strong>Background: </strong>Clopidogrel was added to the national formulary of the Veterans Health Administration (VHA) in 2000, with national guidance in the form of Criteria for Use (CFU) generated in 2007 by the Pharmacy Benefits Management office. Although the national CFU restricted the duration of clopidogrel to no more than 30 days following peripheral vascular intervention (PVI) for peripheral artery disease (PAD), each local VHA Veterans Affairs Medical Center (VAMC) determined its own strategies of implementation. Strategies ranged from passive diffusion of information to electronic health record-mandated pharmacist approval for noncompliant CFU prescribing.</p><p><strong>Objective: </strong>To characterize patterns of compliance to restricted duration of clopidogrel and determine the factors associated with compliance.</p><p><strong>Methods: </strong>In a retrospective cohort study, we used the Veterans Affairs Surgical Quality Initiative Program (2007-2022) to identify index PVI performed for PAD and integrated post-PVI medication information from the VA Clinical Data Warehouse. Our primary outcome was to evaluate compliance with the CFU. During the active CFU period (2007-2018), we compared patient, procedural, and VAMC features by CFU compliance and determined their associations with compliance using multivariable logistic regression. We also characterized variation in compliance across the Veterans Integrated Service Network (VISN), VAMC, and surgeons.</p><p><strong>Results: </strong>Among 7,206 PVIs with postoperative clopidogrel, 35% and 26% had post-PVI clopidogrel durations of no more than 30 days during and after the CFU period, respectively. During the active CFU period, we found no strong association among patient, PVI, and VAMC characteristics with compliance. Compliance during the active CFU period varied significantly among VISNs (16%-55%), VAMCs (0%-93%), and surgeons (0%-100%).</p><p><strong>Conclusions: </strong>Adherence to no more than 30 days of clopidogrel post-PVI was low during and after the active CFU period and varied substantially among the VISNs, VAMCs, and surgeons. Given that national guidance implementation was directed by local VHA pharmacies, this study highlights the importance and limitations of local implementation strategies on national guidance compliance.</p>","PeriodicalId":16170,"journal":{"name":"Journal of managed care & specialty pharmacy","volume":"32 5","pages":"613-624"},"PeriodicalIF":3.3,"publicationDate":"2026-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13119478/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147774047","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Real-world adherence, persistence, and health care resource utilization among people with HIV receiving long-acting cabotegravir plus rilpivirine compared with oral antiretroviral therapy in the United States: The ABOVE Study.","authors":"Cindy Garris, Maral DerSarkissian, Rose Chang, Louise Clear, Zhuo Chen, Daisy Liu, Raj Desai, Paula Teichner, Edgar T Overton","doi":"10.18553/jmcp.2026.32.5.584","DOIUrl":"10.18553/jmcp.2026.32.5.584","url":null,"abstract":"<p><strong>Background: </strong>Long-acting cabotegravir + rilpivirine (CAB+RPV LA) is the first US Food and Drug Administration-approved complete long-acting regimen for people with HIV who are virologically suppressed. Long-acting CAB+RPV may alleviate adherence challenges with daily oral therapy.</p><p><strong>Objective: </strong>To evaluate and compare real-world adherence, persistence, and health care resource utilization in people with HIV who switched to CAB+RPV LA vs maintained daily oral antiretroviral therapy (ART).</p><p><strong>Methods: </strong>ABOVE is a retrospective US cohort study using Symphony Health Solutions Integrated Dataverse administrative claims data from January 1, 2020, to August 31, 2023. The study included people with HIV aged 12 years and older on stable oral ART and with continuous clinical activity for at least 12 months before the index date, categorized into people initiating CAB+RPV LA (LA ART cohort) and people remaining on oral ART (oral ART cohort). The index date was defined as the first injection of CAB+RPV LA or imputed for the oral ART cohort. We used standardized mortality ratio weighting based on propensity scores to balance baseline characteristics. Adherence (proportion of days covered ≥0.9 over 12 months following index) and persistence to the index regimen (days from index to earliest of treatment discontinuation or end of follow-up) were compared. A doubly robust logistic regression model estimated the adjusted odds ratio and 95% CI. Health care resource utilization including preventive care was compared using the doubly robust generalized linear model, with results reported as incidence rate ratios and corresponding 95% CIs.</p><p><strong>Results: </strong>After applying eligibility criteria, the study included 1,245 people in the LA ART cohort (mean age, 47 years; 24.1% female). The oral ART cohort included 58,644 people (mean age, 50 years; 23.3% female). In the standardized mortality ratio-weighted analysis, the LA ART cohort had higher adherence rates (73.7% vs 30.1%) and higher persistence (median [IQR], 424 [201, 537] vs 393 [174, 431] days; <i>P</i> < 0.001 for all) compared with the oral ART cohort. Over 12 months, we observed significantly higher odds of adherence for the LA ART vs oral ART cohorts (adjusted odds ratio = 8.06; 95% CI = 6.62-9.81; <i>P</i> < 0.001). The LA ART cohort also had higher rates of vaccinations, cancer and STI screenings, and bone density testing and lower hospitalization rates.</p><p><strong>Conclusions: </strong>People who switched to LA ART had significantly higher 12-month adherence and persistence over the follow-up compared with people remaining on oral ART. Higher key preventive measure rates and lower hospitalization rates among people who switched to LA ART highlight increased medical engagement benefits.</p>","PeriodicalId":16170,"journal":{"name":"Journal of managed care & specialty pharmacy","volume":"32 5","pages":"584-595"},"PeriodicalIF":3.3,"publicationDate":"2026-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13119484/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147773119","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Risk of herpes zoster among adults in the United States initiating immunosuppressive therapy: A retrospective cohort study.","authors":"Justin Carrico, Yong Zhu, Andrea Steffens, Stephanie Gallagher, Mary DuCharme, Nikita Stempniewicz, Justin Gatwood","doi":"10.18553/jmcp.2026.32.4.422","DOIUrl":"10.18553/jmcp.2026.32.4.422","url":null,"abstract":"<p><strong>Background: </strong>Patients immunosuppressed because of disease and/or therapy are at increased risk of developing herpes zoster (HZ) and related complications. However, HZ risk due to immunosuppressive medication remains underexplored across a broad spectrum of medication classes and conditions.</p><p><strong>Objective: </strong>To estimate HZ risk among US adults initiating immunosuppressive therapy, across underlying conditions.</p><p><strong>Methods: </strong>This retrospective study used administrative claims from the Optum Research Database (October 1, 2015, to December 31, 2022) to identify incident HZ diagnoses and the proportion of HZ with complications. Included patients were aged 18 years or older and had at least a 12-month baseline period of continuous enrollment with medical and pharmacy benefits. Analyses produced incidence rates (IRs) of HZ during periods of immunosuppression and nonimmunosuppression and compared patients initiating immunosuppressive therapy (immunosuppressed subcohort) vs matched controls who did not (nonimmunosuppressed subcohort). Cox regression analyses compared HZ hazards and a logistic regression model compared the difference in the occurrence of postherpetic neuralgia (PHN) following HZ diagnosis.</p><p><strong>Results: </strong>In patients initiating immunosuppressive medications (N = 528,283), the overall HZ IR was 18.2 (95% CI = 17.9-18.4) per 1,000 person-years. Patients with the highest IRs were those treated with Janus kinase inhibitors (30.5 [95% CI = 25.0-36.9] per 1,000 person-years), rituximab (27.8 [95% CI = 25.2-30.6] per 1,000 person-years), or cyclophosphamide (27.5 [95% CI = 19.3-38.1] per 1,000 person-years). Patients had a higher HZ risk when using immunosuppressive medications (adjusted hazard ratio 2.86 [95% CI = 2.76-2.95]) and with increasing numbers of immunosuppressive medication classes (one vs none: 2.45 [95% CI = 2.37-2.54]; at least 2 vs none: 4.04 [95% CI = 3.87-4.21]). The immunosuppressed subcohort had a higher HZ hazard (adjusted hazard ratio: 1.39 [95% CI = 1.35-1.43]), higher frequency of HZ complications (21.4% vs 18.8% of HZ cases developed PHN, <i>P</i> < 0.001), and increased odds of PHN (adjusted odds ratio: 1.22 [95% CI = 1.14-1.31]) compared with the nonimmunosuppressed subcohort.</p><p><strong>Conclusions: </strong>Immunosuppressive medication use was associated with a higher risk of HZ and HZ-related complications. Measures to prevent HZ before immunosuppressive treatment initiation should be considered according to Advisory Committee on Immunization Practices recommendations and other professional organizations.</p>","PeriodicalId":16170,"journal":{"name":"Journal of managed care & specialty pharmacy","volume":"32 4","pages":"422-433"},"PeriodicalIF":3.3,"publicationDate":"2026-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13020775/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147512765","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The impact of data source on real-world medication adherence and exposure measures: From prescription to sold.","authors":"Yifan Zheng, Karen B Farris, Antoinette B Coe, Michael P Dorsch, Kayvan Najarian, Corey A Lester","doi":"10.18553/jmcp.2026.32.4.434","DOIUrl":"10.18553/jmcp.2026.32.4.434","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Background: &lt;/strong&gt;Medication adherence is central to evaluating treatment effectiveness, reducing preventable complications, and informing value-based care. The proportion of days covered (PDC) is widely used but inconsistently calculated across studies because of variations in data sources and methods. Prescription timestamps (written, filled, and sold) capture different stages of the medication journey; however, their impact on adherence measures has not been systematically compared.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Objective: &lt;/strong&gt;To evaluate how different prescription data sources and calculation methods influence medication adherence estimates in real-world practice.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods: &lt;/strong&gt;We conducted a retrospective cohort study of cardiovascular prescriptions (2009-2019) using longitudinal transaction data. Each prescription included written, fill, and medication sold (pickup) dates. Adults with at least 12 months of follow-up and 3 or more prescriptions in the same class (angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers [ARBs], calcium channel blockers, or diuretics) were included (N = 7,226). Two adherence measures were calculated: (1) exposure PDC, reflecting raw coverage without gap adjustments, and (2) adherence PDC, which excluded prolonged gaps using dynamic patient-specific thresholds. PDC was calculated using 5 source definitions (written, fill, sold, written-sold, and fill-sold). Adherent classification agreement at the 0.80 threshold was assessed using cross-tabulations and visualized with Sankey diagrams.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;Patients contributed more than 230,000 fills. Median fill and sold lags were both 0 days, and the 90th percentile delays were longer for fills (29 days) than for sold (3 days). Exposure PDC varied substantially across sources (median = 0.747-0.794; &lt;i&gt;P&lt;/i&gt; &lt; 0.001), whereas adherence PDC was uniformly high (0.959-0.977; &lt;i&gt;P&lt;/i&gt; &lt; 0.001). Written dates produced the lowest exposure PDC because of inflated observation windows and gaps, and sold dates yielded the highest. Across drug classes, ARBs had the highest adherence (exposure median = 0.850; adherence = 0.958) and diuretics the lowest (0.720; 0.952). At the 0.80 threshold, adherence classification was stable for adherence PDC (&gt;94% concordance across sources) but highly sensitive for exposure PDC, with more than 15% of patients switching classification when written dates were used instead of fills.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions: &lt;/strong&gt;Adherence measurement is not fixed but shaped by data source and methodology. Both timestamp choice and gap-handling substantially influence adherence estimates and patient classification. Our dynamic, patient-specific approach to gap adjustment yielded stable metrics, and exposure-based measures remained more source-sensitive. Standardizing and transparently reporting adherence definitions is essential to avoid misclassification. Future work should evaluate the prognostic val","PeriodicalId":16170,"journal":{"name":"Journal of managed care & specialty pharmacy","volume":"32 4","pages":"434-444"},"PeriodicalIF":3.3,"publicationDate":"2026-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13020390/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147512723","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Shared visits vs incident-to billing for pharmacy services.","authors":"Eric Dietrich, Elaina Rosario, Sara M Panella","doi":"10.18553/jmcp.2026.32.4.494","DOIUrl":"10.18553/jmcp.2026.32.4.494","url":null,"abstract":"<p><p>Pharmacists deliver high-value cognitive services in the ambulatory care setting; however, lack of provider recognition under the Social Security Act restricts their ability to independently deliver billable clinical services and access reimbursement through national payers such as Medicare Part B. This often raises the question of whether the collaborative efforts of a pharmacist and a billing provider (eg, physician) during a patient encounter can be combined as a \"shared visit\" to bill for a higher level of service (LOS). However, a distinction must be made between shared visits and \"incident-to\" billing. In an incident-to model, in which a pharmacist sees the patient alone under billing provider supervision, the service can only be billed at the lowest level, 99211, according to Medicare as of 2026. Even when both a pharmacist and billing provider see the patient and contribute to the visit, the pharmacist's documentation cannot be used to determine the LOS because they are not a recognized billing provider; only the billing provider's documented work counts for billing purposes. However, this should not deter collaboration between pharmacists and other health care providers given the clinical benefits of team-based care. With evolving billing requirements tied to documentation of the billing provider, opportunities remain to establish sustainable collaborative care models despite limitations in leveraging combined pharmacist-billing provider documentation to increase LOS through a shared visit model.</p>","PeriodicalId":16170,"journal":{"name":"Journal of managed care & specialty pharmacy","volume":"32 4","pages":"494-497"},"PeriodicalIF":3.3,"publicationDate":"2026-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13020381/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147512681","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Challenges of the Inflation Reduction Act for long-term care pharmacy: Examining impact and policy solutions.","authors":"Shiven Bhardwaj, Howard Weston Schmutz, Jonathan H Watanabe, Douglas Barthold","doi":"10.18553/jmcp.2026.25312","DOIUrl":"10.18553/jmcp.2026.25312","url":null,"abstract":"<p><p>The Inflation Reduction Act of 2022 contains several health care provisions aimed at reducing costs for Medicare beneficiaries. Although these goals are critical, the legislation may have unintentional adverse impacts on long-term care (LTC) pharmacies. This article examines how specific provisions of The Inflation Reduction Act of 2022 may destabilize the LTC pharmacy sector, creating barriers to access for LTC residents.We analyze the financial implications of the Medicare Drug Price Negotiation Program, illustrating how the shift to maximum fair price reimbursement combined with inadequate dispensing fees could result in an estimated revenue decline of more than 85% for drugs selected within the program. We also outline how new payment flows for the maximum fair price involving the Medicare Transaction Facilitator will likely extend reimbursement timelines, creating liquidity challenges for pharmacies operating on thin margins.Beyond finances, we discuss operational conflicts with the Medicare Prescription Payment Plan. Specifically, we argue that alerting requirements are incompatible with LTC workflows and pose unnecessary administrative burden on pharmacies. To address these vulnerabilities, we propose near-term legislative and regulatory remedies, including appropriating funds to ensure timely manufacturing payments and codifying the standard default refund amount to protect acquisition discounts. Finally, we recommend structural reforms that shift reimbursement away from volume-based models to value-based care. By aligning payment with patient outcomes, policymakers can ensure the financial sustainability of LTC pharmacies and the continued delivery of highly effective pharmaceutical care to the nation's aging population.</p>","PeriodicalId":16170,"journal":{"name":"Journal of managed care & specialty pharmacy","volume":" ","pages":"498-506"},"PeriodicalIF":3.3,"publicationDate":"2026-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13020388/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146157222","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Economic evaluation of ponatinib vs reference and generic imatinib in front-line management of philadelphia chromosome-positive acute lymphoblastic leukemia: A value dilemma.","authors":"Rosemond Sussana Amamoo, Brielle Schuerman, Mavis Obeng-Kusi, Seongseok Yun, Brian Erstad, Ivo Abraham","doi":"10.18553/jmcp.2026.32.4.413","DOIUrl":"10.18553/jmcp.2026.32.4.413","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Background: &lt;/strong&gt;Acute lymphoblastic leukemia (ALL) mainly affects children, though it also occurs in adults. About 25% of adults with ALL have the more aggressive Philadelphia chromosome-positive (Ph+) subtype. Standard treatment includes tyrosine kinase inhibitors (TKIs) in combination with chemotherapy or corticosteroids, which have greatly enhanced survival rates over the past 2 decades. Ponatinib, a third-generation TKI demonstrated greater efficacy compared with imatinib, a first-generation TKI, in the PhALLCON trial.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Objective: &lt;/strong&gt;To conduct an economic evaluation of ponatinib compared with (1) reference imatinib, (2) the average cost of several imatinib generics, and (3) the weighted cost of imatinib in adults with Ph+ ALL from the US payer perspective.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods: &lt;/strong&gt;Cost-effectiveness and cost-utility analyses were performed using a partitioned survival model with 3 mutually exclusive health states: progression-free, progressed disease, and death. A time horizon of 60 months and a 3% discount rate were applied. The incremental costs per 1% gain in probability of progression-free survival and overall survival at 60 months were estimated.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;Life-years (LYs) and quality-adjusted LYs (QALYs) were higher for ponatinib (3.74, 2.15) than for imatinib (3.52, 1.68). Compared with reference imatinib, ponatinib was dominant, having cost savings of $56,024. Compared with average generic imatinib, ponatinib had an incremental cost of $147,147, yielding an incremental cost-effectiveness ratio (ICER) of $668,150 per LY gained and incremental cost-utility ratio (ICUR) of $314,646 per QALY gained. Compared with weighted imatinib, ponatinib had an incremental cost of $128,861, yielding ICER of $585,122 per LY gained and ICUR of $275,546 per QALY gained. The differential cost of ponatinib per patient for a 1% increase in the probability of remaining in the progression-free survival state was $6,883 in savings compared with reference imatinib, but an additional $18,077 compared with average generic imatinib and $15,835 compared with weighted imatinib.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions: &lt;/strong&gt;Ponatinib demonstrated cost savings relative to reference imatinib, though its incremental costs were substantially higher when compared with both average and weighted imatinib, for an approximate gain of 3 months of life and 6 months of quality-adjusted life. This presents a value dilemma: whether to save money with more affordable alternatives for a slightly lower clinical benefit, possibly parlaying these cost-efficiencies into expanded patient access. This highlights the challenge of balancing clinical benefits with economic sustainability, particularly when the modest health gains come at a substantially higher cost. Although ponatinib offers therapeutic value, payers and policymakers must carefully evaluate whether the clinical outcomes justify the additional costs, considering also its ","PeriodicalId":16170,"journal":{"name":"Journal of managed care & specialty pharmacy","volume":"32 4","pages":"413-421"},"PeriodicalIF":3.3,"publicationDate":"2026-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13020392/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147512756","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}