Managed Care Has Experienced Numerous Changes Since the First Publication of AJMC®: John M. O'Brien, PharmD, MPH

John Michael O'Brien, PharmD, MPH, a member of AJMC’s editorial board and the president and CEO of the National Pharmaceutical Council (NPC), spoke about how he believes managed care has changed since The American Journal of Managed Care® first published in 1995.

This transcript has been lightly edited for clarity; captions are auto-generated

Transcript

How has the concept of managed care and the conversations around it changed over the past 30 years?

Over my 30 years in health care, I’ve seen managed care go from being a derogatory term that referred to stinting on care to achieve PMPM [per-member per-month] savings to being a movement that embraced better health, better care, and lower total health care costs. But today, managed care is at an inflection point, and there are questions about the value that managed care plans provide against a backdrop that includes a dynamic policy environment and really important questions about the role of consolidation and vertical integration, cost-containment strategies, or the use of artificial intelligence. Additionally, as health care costs continue to go up, stakeholders like employers are starting to pay attention in ways that they weren’t 30 years ago.

Making sure the right patient gets the right care at the right time is still goal number 1, whether we’re talking about accessing pharmacy benefits or medical benefits. But all too often, that’s not what patients describe that they’re experiencing. When you think about the drug side, patients are more likely to use a pharmacy more often than they are to see a physician or be admitted to a hospital, and that’s a good thing, but the pharmacy counter is oftentimes where patients experience delays, denials, or higher out-of-pocket costs, and that’s not good for patients. This is something we spend a lot of time thinking about here at NPC. We envision a world where advances in medicine are accessible to patients, valued by society, and sustainably reimbursed by payers to ensure continued innovation. Payers are and always should be concerned about the cost of care, but making sure we have an informed conversation about the bang for the buck that medicines deliver and how they help people get well, stay healthy, and avoid more costly care settings is really important to the future of managed care.

Today, we’re living in a golden age of biomedical innovation, and many of the medicines that are available today would have been considered science fiction when I was in pharmacy school 30 years ago. Back then, we didn’t have a pill to treat breast cancer or cure hepatitis C. We couldn’t have imagined long-acting injectables that prevent the transmission of HIV, let alone the promise of some of today’s cell and gene therapies. These treatments are tools that can help managed care plans achieve better population health and ultimately lower health care costs down the road. So we look forward to contributing to that conversation over the next 30 years by conducting research and publishing it in AJMC and other peer-reviewed journals, and continuing to help manage care and the discussion around it evolve.