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The purposes of this study was to review the pharmacy benefit management and quality control of health insurance body in Korea and United States. In Korea, 3 government organizations (Ministry of Health and Welfare, National Health Insurance Corporation, Health Insurance Review & Assessment Service) participate in the pharmacy benefit management including ‘formulary management’, ‘drug price control’, and ‘drug utilization management’. So far the trial for the quality control of the management has been focused on administrative affairs rather than core functional value. Quality control tools include public management evaluation and audit for government agents. On the other hand, In United States, companies called PBM (Pharmacy Benefit Management) take a major roles regarding to management of all reimbursed drugs. Since there are many kinds of PBMs in US, organizations which controls the quality were established. All functions managed by PBM has been checked regularly in terms of quality improvement. Those programs include the Pharmacy Benefit Management Accreditation Standards, Version 1.0 published by URAC, and 2010 NCQA Health Plan Accreditation Requirements published by NCQA. It is highly required to develop quality assessment tool for improving pharmacy benefit management in Korea. Quality control based on the assessment will ensure patients a pharmaceutical care.

Introduction To improve patient safety and appropriateness of drug usage in Korea, a DUR program has been operated by HIRA since 2008. However, the quality of the program has never been verified although it is the only DUR processing tool used nationwide. Purpose The aim of this study is to examine the sensitivity and specificity of the program focused on drug-drug interactions within and between prescriptions. Method A total of 655,928 prescriptions issued in a 650-bed hospital for 6 months were analyzed using HIRA-DUR program and a drug-interaction detection module developed by DIF-KOREATM (DI-module). In this study, the DI-module was adopted as a golden standard because it has been made up with a number of reliable references recommended by OBRA’0 and complemented with information on korean local drugs. Result The sensitivity and specificity of the HIRA program in detecting drug-interaction were 17.99% and 99.83%, respectively, when compared with the DI-module. Discussion Reasons for the differences could be speculated as follows; I) There were medicines not been checked by the HIRA program because they were not in national formulary or they were combination drugs. ii) The program did not include some pairs of active ingredients related to possible drug interaction because KFDA announced a list of them partially. iii) Certain dosage strength and forms of some KFDA-announced active ingredients were left out from the possible drug-interaction list of the HIRA program. Conclusion It is concluded that an effort to update the most recent information and to manage the possible drug-interaction list should be made on regular base by related organizations such as HIRA and KFDA to improve safety of patients in drug use.