Amcp dossier definition7/26/2023 ![]() Actuaries tend to create outcome measures in terms of PMPM cost rates, rather than composite measures like cost-effectiveness ratios. Actuaries also incorporate variables such as trends, dynamic-population analysis, and adjustments for other factors like plan-benefit design (e.g., covered services and copayments) and internal financial structure (e.g., financial incentives for providers). This analysis is based on modeling that incorporates outcomes and dollars, and utilizes actuarial inputs or techniques. The financial health of the health plan relies on the actuarial department's calculations. A primary function of health plan actuaries is to ensure that the premium charged for coverage will be adequate for the health plan to cover claims and other expenses. Pharmacoactuarial analysis produces economic models that can help companies meet AMCP guidelines and demonstrate a treatment's value in a way that formulary committees can understand and use.Īn actuary specializes in the mathematics of risk, especially as it relates to insurance calculations such as premiums, dividends, reserves, and insurance and annuity rates. This is most useful for pricing and monitoring of experience compared with expectation, both important financial functions within a health plan.Ĭonsequently, pharmaceutical man-ufacturers should consider the importance of providing information that catches the attention of those outside the P&T Committee, particularly the actuarial department. To do this, the information provided would need to show elements of a health plan budget, as well as how utilization and per-member per-month (PMPM) claim costs may be impacted by the addition of the new drug. While CE model results are worthwhile, especially in coming to a yes-or-no coverage decision-e.g., "the $45,000 per QALY gained passes our test for inclusion as a preferred drug"-they don't help with monitoring of experience or health plan pricing. Such questions include requests for information tailored to a health plan, with overt specification as to the greater impacts of formulary decisions on the health plan as a whole as well as its members and specific demonstration of value compared with competitors. What are the expected impacts on pharmacy, hospital, and physician budgets?Ĭlearly, these questions go beyond the generic cost-effectiveness results typically provided by manufacturers.What about the reimbursement, utilization, and morbid-outcome assumptions made in modeling these data? How does this intervention stack up against other available treatments?.How will the older-than-average age of our population affect outcomes?.Then the committee starts asking questions: ![]() The model demonstrates that the drug is cost-effective while it costs 50 percent more per pill and has a rare-but-catastrophic side effect, it results in a 50 percent increase in quality-adjusted life years (QALYs) compared to another treatment. A drug company representative has provided the dossier, including a cost-effectiveness (CE) model that meets the requirements laid out by the Academy of Managed Care Pharmacy (AMCP) Format for Formulary Submissions. It happens in health plans all over the country: Pharmacy and Therapeutics Committees meet to consider the placement of a new drug on the formulary.
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