PubMed · 16686237
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Christopher Newdick. 2005. Accountability for rationing--theory into practice.. https://doi.org/10.1111/j.1748-720x.2005.tb00534.x
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Once enrolled in a Medicare Part D prescription plan, the focus changes to access to medically necessary medications through the prescription plan. In many situations, this will involve the exceptions and appeals process. Each Medicare plan has its own drug formulary and differentiates itself through various parameters within those formularies. The federal government has rules in place for what may or may not be covered in a formulary, and has specified parameters for an exceptions and appeals process. It is the responsibility of the patient, along with his or her physician, to learn about and take advantage of mechanisms built into the system to ensure access to medically necessary medications. As physician reimbursement moves to an outcome-based through pay-for-performance system, physicians will have a financial incentive for assuring that their patients receive the necessary medications.
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On the heels of widespread patient protection legislation in the states, the managed care industry abandoned or greatly scaled back the core elements of gate-keeping, utilization management, and financial incentives, which are the very targets of this legislation. This article explores whether, and to what extent, the industry's abrupt change in course can be attributed to these laws. Based on extensive interviews with key informants in six representative states, the article concludes that these laws were not the primary driver of changes in managed care practices. However, patient protection laws interacted with other social and market forces, through complex forms of feedback and reinforcement, to bring about more thoroughgoing change than would have otherwise occurred.