• The most important factors in formulary decision making have been reported to be safety, effectiveness, and efficacy, with FDA approval status, availability of alternatives, and acquisition cost of drugs also considered.• Spooner et al. (2007) ABSTRACTBAckground: Advancements in biologics and personalized medicine and the implementation of national prescription drug policies have likely prompted payers to implement additional health technology assessment and cost-containment strategies. A payer's decision to provide coverage for a drug and its associated benefit design draws on information from many sources. However, there is an incomplete understanding of the process employed and the criteria applied in formulary assessments of pharmaceuticals by public and private health plans.

The PGP demonstration, which used a payment model similar to the Medicare Accountable Care Organization (ACO) program, resulted in small reductions in Medicare expenditures and inpatient utilization, and improvements in process quality indicators. Judging from this demonstration experience, it is unlikely that Medicare ACOs will initially achieve large savings. Nevertheless, ACOs paid through shared savings may be an important first step toward greater efficiency and quality in the Medicare fee-for-service program.

The healthcare system's rapid shift toward value-based payment poses unique quality measurement challenges and new foci for researchers and policy makers. Quality measures that use sex-specific criteria may inappropriately include or exclude transgender individuals. More large-scale studies must be conducted to incorporate transgender individuals into measures that use sex-specific criteria, and "measure stewards" should consider the existing clinical guidelines and recommendations regarding transgender individuals when developing measures. Systems designed only for cisgender individuals will exacerbate existing transgender healthcare disparities unless they are revamped and flexible to transgender individuals' needs.

The eight-year provider evaluation of the Massachusetts Behavioral Health Program showed positive assessments of care provision, continuing problems in integration of care, high assessments of the clinical review process, high evaluations for administration, and positive ratings compared with other managed care organizations. Changes in provider organizations continue. Substance abuse and mental health providers gave similar ratings, while inpatient providers were more critical than outpatient providers. Ratings in Year 8 were higher generally than in Year 7. The program continues to be a success; however, improvement in several areas continues to be difficult.