Drug Utilization Review Under Medicare

T-PEMD-89-5: Published: Aug 1, 1989. Publicly Released: Aug 1, 1989.

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GAO discussed the proposed Health Care Financing Administration (HCFA) drug utilization review system, focusing on: (1) drug safety; (2) the proposed system's development and implementation; and (3) pharmacy participation. GAO found that: (1) research on prescription practices for the elderly indicated that inappropriate drug prescription could cause adverse drug reactions which could lead to drug-induced illnesses, hospitalization and possible death and add to health care expenditures; (2) recent legislation required an electronic system that pharmacies would use to verify Medicare eligibility, keep Medicare drug purchase records, process and pay bills, and review drug utilization; (3) the proposed system would not include individual medication profiles or information on drug allergies or over-the-counter drugs, which could help pharmacists make appropriate prescription judgments; (4) the proposed system would have limited ability to detect drug interactions, excessive dosages, and duplicative drug therapies, and would be focused more on the general public than the elderly; (5) HCFA procedures for reviewing drug utilization did not focus on quality-of-care issues or on merging patient diagnosis information from Medicare claims with prescription information; (6) HCFA may not have sufficiently planned for testing whether information from the three independently developed regional systems would be efficient; and (7) HCFA may not have sufficient pharmacy participation.

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