Does Medicalization of Life Imperil Health? Expanding Indications for Diagnosis and Treatment of Chronic “Disease”

Fairman, Kathleen A.; Curtiss, Frederic R.

doi:10.18553/jmcp.2011.17.6.469

Cited by 3 publications

(2 citation statements)

References 47 publications

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“…13,14 Employer-PBM arrangements began to shift toward greater PBM influence as drug spending increased rapidly beginning in the 1990s, fueled by "blockbuster" drug launches, coverage expansions, and increasingly broad definitions of chronic disease. [15][16][17] Employers and other plan sponsors gradually relinquished control of the benefit, making decisions about design features (e.g., copayments, deductibles) but delegating key business arrangements like network contracting, price negotiation, formulary coverage, and utilization management to the PBM. 13,18 More recently, double-digit specialty drug cost increases and concerns about the transparency of PBM business practices led to growing consensus that this delegated model was no longer working well for many employers and patients.…”

Section: ■■ Foundation Of Drug Benefit Management In Early Pbm Business Modelsmentioning

confidence: 99%

Changes in PBM Business Practices in 2019: True Innovation or More of the Same?

Motheral¹,

Fairman²

2020

JMCP

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In 2019, pharmacy benefit managers (PBMs) responded to intense public criticism with business model changes described as movements toward full transparency and innovation to reduce costs for benefit plan sponsors. We critically analyze these changes in light of key challenges in specialty drug management: pharmaceutical manufacturer practices (price increases driven by coverage mandates and lack of price control, intensive and sometimes misleading advertising, patent extensions), FDA changes (increased reliance on manufacturer funding, weakened evidentiary base for drug approvals), and provider prescribing patterns (lag from evidence to routine practice, manufacturer influences on the knowledge base, direct manufacturer payments to frequent prescribers).The persistence of controversial PBM practices suggests that business model changes were mostly cosmetic, without altering key marketplace dysfunctions. Examples include "spread" pricing, in which PBMs pay pharmacies less than employer-paid amounts; rebate-influenced formulary development; and shifting of prescription volume to PBM-owned pharmacies. Spread in Medicaid was estimated at $224.8 million in Ohio and $123.5 million in Kentucky in 1-year periods and is the subject of an ongoing federal investigation. Rebate influence on formulary development is suggested by slow biosimilar adoption and a study documenting little association between brand exclusions and clinical or cost-effectiveness. Even in 100% passthrough arrangements, the price differential between rebated products and lower-cost alternatives may far exceed revenues returned to the payer. Shifting of business to PBM-owned pharmacies was identified in Florida managed Medicaid in 2018, where the state's 5 largest specialty pharmacies, all owned by managed care organizations or PBMs, collected 28% of prescription drug profit despite dispensing only 0.4% of claims. Finally, contract provisions and terms typically limit the ability of plan sponsors to monitor PBM performance. These include "offsetting," changes in definitions (e.g., "single-source generic") during the contract term, restrictions on audit rights, and exclusion of some pharmaceutical manufacturer revenues from "100%" passthroughs. We conclude that ostensibly positive changes in PBM practices have been offset by undisclosed business arrangements, shifts to alternative revenue sources, and opaque contractual terms. Establishing and maintaining a sustainable benefit will require fundamental alterations to this dysfunctional market

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Section: ■■ Foundation Of Drug Benefit Management In Early Pbm Business Modelsmentioning

confidence: 99%

Changes in PBM Business Practices in 2019: True Innovation or More of the Same?

Motheral¹,

Fairman²

2020

JMCP

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“…Research published within the past few years suggests an explosion in the treatment of conditions that previously had been subjects of "watchful waiting" or nonpharmacologic approaches [4]. Examples of medicalized disorders include menopause, alcoholism, attention deficit hyperactivity disorder (ADHD), posttraumatic stress disorder (PTSD), anorexia, infertility, sleep disorders, and erectile dysfunction (ED) [3].…”

Section: The Medicalization Of Obesitymentioning

confidence: 99%

Medicalizing Obesity: Individual, Economic, and Medical Consequences

Blackburn

2011

AMA Journal of Ethics

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Defining MedicalizationAs Sadler and colleagues [1] define it, "'medicalization' describes a process by which human problems become defined and treated as medical problems" [2]. According to Conrad and colleagues [3], medicalization, like globalization or secularization, is neither good nor bad; it merely notes that a condition has come under medical jurisdiction. Others suggest that the term does imply something suspect-that a normal variation in health or behavior has been annexed, in whole or in part, by the apparatus of medicine [3]. The Medicalization of ObesityResearch published within the past few years suggests an explosion in the treatment of conditions that previously had been subjects of "watchful waiting" or nonpharmacologic approaches [4]. Examples of medicalized disorders include menopause, alcoholism, attention deficit hyperactivity disorder (ADHD), posttraumatic stress disorder (PTSD), anorexia, infertility, sleep disorders, and erectile dysfunction (ED) [3].

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Cross-sectional analysis of the prevalence and predictors of statin utilisation in Ireland with a focus on primary prevention of cardiovascular disease

et al. 2018

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ObjectiveTo describe the prevalence of statin utilisation by people aged over 50 years in Ireland and the factors associated with the likelihood of using a statin, focusing particularly on those using statins for primary prevention of cardiovascular disease (CVD).MethodsThis is a cross-sectional analysis of cardiovascular risk and sociodemographic factors associated with statin utilisation from wave 1 of The Irish Longitudinal Study on Ageing. A hierarchy of indications for statin utilisation, consisting of eight mutually exclusive levels of CVD-related diagnoses, was created. Participants were assigned one level of indication. The prevalence of statin utilisation was calculated. The likelihood that an individual was using a statin was estimated using a multivariable logistic regression model, controlling for cardiovascular risk and sociodemographic factors.ResultsIn this nationally representative sample (n=5618) of community-dwelling participants aged 50 years and over, 1715 (30.5%) were taking statins. Of these, 65.0% (57.3% of men and 72.7% of women) were doing so for the primary prevention of CVD. Thus, almost two-thirds of those taking statins did so for primary prevention and there was a notable difference between women and men in this regard. We also found that statin utilisation was highest among those with a prior history of CVD and was significantly associated with age (compared with the base category 50–64 years; 65–74 years OR 1.38 (95% CI 1.16 to 1.65); 75+ OR 1.33 (95% CI 1.04 to 1.69)), living with a spouse or partner (compared with the base category living alone; OR 1.35 (95% CI 1.10 to 1.65)), polypharmacy (OR 1.74 (95% CI 1.39 to 2.19)) and frequency of general practitioner visits (compared with the base category 0 visits per year; 1–2 visits OR 2.46 (95% CI 1.80 to 3.35); 3–4 visits OR 3.24 (95% CI 2.34 to 4.47); 5–6 visits OR 2.98 (95% CI 2.08 to 4.26); 7+ visits OR 2.51 (95% CI 1.73 to 3.63)), even after controlling for clinical need. There was no association between using statins and gender, education, income, social class, health insurance status, location or Systematic Coronary Risk Evaluation (SCORE) risk in the multivariable analysis.ConclusionStatin utilisation among those with no history of CVD accounted for almost two-thirds of all statin use, in part reflecting the high proportion of the population with no history of CVD, although utilisation rates were highest among those with a history of CVD.

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Does Medicalization of Life Imperil Health? Expanding Indications for Diagnosis and Treatment of Chronic “Disease”

Cited by 3 publications

References 47 publications

Changes in PBM Business Practices in 2019: True Innovation or More of the Same?

Changes in PBM Business Practices in 2019: True Innovation or More of the Same?

Medicalizing Obesity: Individual, Economic, and Medical Consequences

Cross-sectional analysis of the prevalence and predictors of statin utilisation in Ireland with a focus on primary prevention of cardiovascular disease

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