Specialty Pharmacy 3.1

SDrM 5 – Drug Utilization Management Reporting

Submited by: Tom Goddard

The Basics

This brief standard simply requires that your pharmacy has a mechanism by which it provides a report on the drug utilization management program to the quality management committee ("QMC") or some other committee that oversees quality management.
The content of that report is up to the pharmacy, but URAC has an expectation that it will include such information as:

  • The volume of utilization reviews, separated out by type (prospective, concurrent, retrospective, and total). "Concurrent" includes automated/point-of-sale reviews.
  • Instances of over- or under-utilization, clinical abuse, or medication misuse;
  • The frequency of instances in which the prescriber/patient did not provide sufficient data with which to conduct a review.
The report should not merely be raw numbers, but also should include an analysis of those numbers. "Tracking and trending" is a long-standing expectation of URAC's with regard to reports to the QMC.

Management Tips

Be sure that your policy specifies which positions have the responsibility to gather the data, conduct the analysis, and present the report to the QMC. You may even want to include a template report in your policy, although that is not required by the standard.

Accreditation Tips

Desktop Review
You need only submit the P&P that describes the process for providing reporting on drug utilization management activities to the QMC.
Validation Review
The reviewer will interview your clinical leadership about the process of analyzing drug utilization management data and presenting such analysis to the QMC.
Document Review
The reviewer will examine the QMC meeting minutes for evidence that such reports are provided every quarter to the QMC. Be sure to flag the portion of the minutes that contain such evidence so that the reviewer doesn't have to page through pages of minutes in an effort to find that evidence. It also helps to have the report as an attachment to the minutes so that the reviewer can see what was actually reported.