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What is Drug Utilization Review?

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  • Written By: Tricia Ellis-Christensen
  • Edited By: O. Wallace
  • Last Modified Date: 17 November 2016
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Drug utilization review can be defined as review of drugs used in a population (a state, a country, an age group, or subscribers of a health insurance plan) to determine effectiveness, potential dangers, problems with drug interaction, and other issues. There are drug utilization review boards that are private and might work for health insurance or pharmacy companies. As of 1993, with the passage of the Omnibus Budget Reconciliation Act of 1990, every US state also must have a drug utilization review board that oversees outpatient prescriptions for Medicaid patients, and these make recommendations about best prescription drugs, drug problems and drug interactions, which are available to pharmacists and physicians.

There are reasons why oversight of what is prescribed can be so vital. With thousands of potential drugs available, combinations of medications can quickly become lethal, or they make people so sick that it dramatically increases medical costs. It is fair to state that people have died from prescribed medications that should not have been prescribed together or that were taken incorrectly. Having boards or private organizations that oversee potential interactions and make certain physicians and pharmacists are aware of them is valuable.

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In some cases a drug utilization review board mandates that pharmacists speak to people when they are prescribed new medications. This won’t stop all potentially deadly interactions unless patients are forthcoming about what they’re taking. The practice of doctor shopping to gain prescriptions from several physicians, especially for those people who pay privately instead of through an insurance company, may be hard to track. Still the majority of people receive prescriptions from one physician or maybe a couple, and if they fill them at the same pharmacy, this can be tracked.

One intervention that may occur with drug utilization review is that a pharmacist may not fill a prescribed drug if he sees a patient is on something else with which it will conflict. Ideally this intervention should occur at the doctor’s office, but it doesn’t always. Pharmacists or doctors can also perform what is called retrospective drug utilization review to evaluate what medicines a patient is currently taking, and perhaps make changes if needed to more effective or more appropriate drugs.

An aspect of drug utilization review that is not so savory to some critics is this issue of review for cost saving measures. In systems like Medicaid and in many health plans, certain medications are “preferred,” even if they are not the best treatment for everyone. Statistically, preferred medications are usually fairly effective, but they also may be the cheapest, and not always best. While many people support review that can save lives, they feel uncomfortable or are soundly against the idea of using an oversight committee to make recommendations about drugs based on a cost factor. In some instances, cutting costs may not be weighed equally with the health priorities of the individual.

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babylove
Post 4

@wizup – The Medicare drug plan she chooses depends mostly on the medications she’s taking. As you know, not all drugs are covered. My plan costs around $30.00 month and offers free generic and I get partial coverage for my name brand prescriptions.

It really is a personal call on how much she can afford to spend and what type of meds she’s taking. One thing you need to be aware of though is that there are penalties she’ll have to pay if she waits at getting the Part D coverage later on.

wizup
Post 3

I think the real problem here is the drug utilization committee and the Medicare preferred drug programs. My mom just turned 65 and is now eligible for it, but how do you determine which plan is the right one? Are the Medicare part d plans worth it?

She takes numerous prescriptions for breast cancer, lupus, thyroid, high blood pressure and depression. She can’t do without any of her meds even for a day. I don’t have the names of them all in front of me right now, but what I’m wondering is, will Medicare alone be enough to cover her prescriptions or is it worth spending the extra money for additional coverage?

whitesand
Post 2

@ISay - I agree with you that drug utilization management should be performed at the highest level, but no matter who conducts the reviews, doesn’t it all come down to the responsibility of our physicians and pharmacists to utilize them? They are the ones administering the drugs and dispensing them to the patients.

Don’t get me wrong I’m not blaming anyone here. What I’m saying is that the reviews are available to both physicians and pharmacists alike and for the most part they’re doing a good job. But in my opinion not enough is being done to thoroughly investigate prescription drug usage on a patient level.

It’s ultimately the patients responsibility to know what their taking and to ask questions. But if they’ve developed and addiction or are doing something illegal, or even if their just following doctors orders, then the responsibility falls back on the medical profession.

ISay
Post 1

Drug utilization reviews have only become the responsibility of the states because big pharmaceutical companies aren't taking the time to fully research and determine the effects of the drugs they're producing and distributing.

I say it shouldn't be up to states and taxpayers to cover the expense of drug utilization reviews, but the companies that manufacture the drugs in the first place should cover the expense of reviews.

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