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KMID : 1022920110030010001
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Journal of Korean Academy of Social & Managed Care Pharmacy
2011 Volume.3 No. 1 p.1 ~ p.15
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Comparison of pharmacy benefit management and quality control of payers : Korea and the United States
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Choi Yoon-Young
Shin Hyun-Taek
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Abstract
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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.
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KEYWORD
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theoretical consideration, health insurance, pharmacy benefit management(PBM), quality control, Korea, United States
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