United States Government Publishing Office publisher pbl distributor dst United States Government Accountability Office Health, Education, and Human Services Division author aut Government Organization text government publication eng GAOREPORTS Legislative Agency Publications gao legislative 2010-08-12 U.S. Government Printing Office 2000-03-22 monographic deposited born digital 15 p. GA 1.13:T-HEHS-00-84 https://www.govinfo.gov/app/details/GAOREPORTS-T-HEHS-00-84 P0b002ee180396917 f:he00084t DGPO 2010-08-12 2011-03-24 GAOREPORTS-T-HEHS-00-84 machine generated eng fdlp REPORT GAOREPORTS-T-HEHS-00-84 T-HEHS-00-84 Health care programs Health insurance Drugs Health insurance cost control Health services administration Private sector practices Managed health care Health resources utilization Pharmaceutical industry Medicare Program Medicare Fee-for-Service Program Medicare Choice Program Medicare Health Maintenance Organizations Program Blue Cross and Blue Shield Insurance Benefit Plan Medigap Medicaid Program Testimony HEHS Pursuant to a congressional request, GAO discussed issues related to a potential Medicare outpatient prescription drug benefit, focusing on: (1) the factors contributing to the rise in prescription drug spending and the impact of the rise in spending on Medicare beneficiaries; (2) the methods private insurers have developed to manage these rising costs; and (3) whether and how Medicare can adapt these methods to control spending, should an outpatient prescription drug benefit be added to Medicare.<p/>GAO noted that: (1) private insurers, managed care plans, and employers have tried to manage the high and rising costs of prescription drugs by adopting cost and utilization control techniques; (2) in many cases, insurers and managed care plans contract with a pharmacy benefit management company (PBM) to develop and implement these strategies; (3) if a prescription drug benefit were added to the Medicare program, the federal government would face similar cost pressures and would need to employ methods to control spending; (4) the experience gained in the private sector can provide useful insights into options for managing a possible Medicare benefit; (5) however, the unique responsibilities and characteristics of the Medicare program raise a number of issues and introduce questions about applying private sector tools to the traditional Medicare fee-for-service program and the appropriate roles of the Health Care Financing Administration and other entities, such as PBMs, in managing a drug benefit; and (6) in adapting these cost and utilization management techniques, it is important to keep in mind that: (a) strategies involving coverage restrictions impose an obligation to provide beneficiaries with adequate information about the benefit; (b) the size of the Medicare program and the need for transparency in its actions may reduce the effectiveness of some cost-control techniques; (c) using private sector entities to implement a drug benefit introduces concerns related to beneficiary equity and concentrating market power; and (d) private sector management tools require a capacity to process and scrutinize a large number of claims more quickly than is typical of the traditional Medicare program. https://www.govinfo.gov/content/pkg/GAOREPORTS-T-HEHS-00-84/html/GAOREPORTS-T-HEHS-00-84.htm https://www.govinfo.gov/content/pkg/GAOREPORTS-T-HEHS-00-84/pdf/GAOREPORTS-T-HEHS-00-84.pdf GAO/T-HEHS-00-84 https://www.govinfo.gov/app/details/GAOREPORTS-T-HEHS-00-84 Testimony GAO/T-HEHS-00-84; Prescription Drug Benefits: Applying Private Sector; Health care programs Health insurance Drugs Health insurance cost control Health services administration Private sector practices Managed health care Health resources utilization Pharmaceutical industry Medicare Program Medicare Fee-for-Service Program Medicare Choice Program Medicare Health Maintenance Organizations Program Blue Cross and Blue Shield Insurance Benefit Plan Medigap Medicaid Program