Standardized Review and Approval Process for High-Cost Medication Use Promotes Value-Based Care in a Large Academic Medical System.

backgroundAs healthcare costs rise and reimbursements decrease, healthcare organization leadership and clinical providers must collaborate to provide high-value healthcare. Medications are a key driver of the increasing cost of healthcare, largely as a result of the proliferation of expensive specialty drugs, including biologic agents. Such medications contribute significantly to the inpatient diagnosis-related group payment system, often with minimal or unproved benefit over less-expensive therapies.

objectiveTo describe a systematic review process to reduce non-evidence-based inpatient use of high-cost medications across a large multihospital academic health system.

methodsWe created a Pharmacy & Therapeutics subcommittee consisting of clinicians, pharmacists, and an ethics representative. This committee developed a standardized process for a timely review (<48 hours) and approval of high-cost medications based on their clinical effectiveness, safety, and appropriateness. The engagement of clinical experts in the development of the consensus-based guidelines for the use of specific medications facilitated the clinicians' acceptance of the review process.

resultsOver a 2-year period, a total of 85 patient-specific requests underwent formal review. All reviews were conducted within 48 hours. This review process has reduced the non-evidence-based use of specialty medications and has resulted in a pharmacy savings of $491,000 in fiscal year 2016, with almost 80% of the savings occurring in the last 2 quarters, because our process has matured.

conclusionThe creation of a collaborative review process to ensure consistent, evidence-based utilization of high-cost medications provides value-based care, while minimizing unnecessary practice variation and reducing the cost of inpatient care.