title: AHRQ's Effective Health Care Program: its impact on managed care.
abstract: OBJECTIVE
  To describe some of the managed care perspectives regarding the data development and coverage issues.
  
  
  BACKGROUND
  Section 1013 of the Medicare Modernization Act of 2003 has initiated the formation of the Agency for Healthcare Research and Quality (AHRQ) Effective Health Care Program, which is evaluating the treatments for rheumatoid arthritis (RA) in the Medicare population. The results of these studies have the potential to impact future drug utilization. It is not known whether this data could be applied to the commercial population.
  
  
  CONCLUSIONS
  Payers (e.g., managed care organizations, pharmacy benefit managers) make decisions about which drugs will be covered and to which formulary "tier" the drug will be assigned. These decisions are made by evaluating current evidence based on safety, effectiveness, outcomes, and cost. Patients believe in a "warranty" of care, meaning that there will always be a treatment option whether they are compliant with their treatment regimen or not. All treatments are measured by a "value," and each stakeholder may see this value differently. A return on medical investment is one way to assess this value.
  
  
  CONCLUSIONS
  Different stakeholders view treatment value in different ways. The evidence that will be identified through AHRQ's Effective Health Care Program will partially define this value. If this model succeeds, it has the potential to significantly affect health care.
authors: Pharmacy and Clinical Integrations, Humana, Inc., KY 40202, USA. wfleming@humana.com
authors: William K
authors: WK
authors: Fleming
mesh_terms: D001172:Arthritis, Rheumatoid / Q000188:drug therapy*; D006801:Humans; D007356:Insurance, Pharmaceutical Services / Q000191:economics / Q000331:legislation & jurisprudence*; D008329:Managed Care Programs / Q000191:economics / Q000639:trends*; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors*; D014481:United States; D016270:United States Agency for Healthcare Research and Quality / Q000331:legislation & jurisprudence*
chemical_list: D014409:Tumor Necrosis Factor-alpha