The ABCs of Advocacy: Understanding DURs and P&Ts
The ABCs of Advocacy: Understanding DURs and P&Ts
Written by Joe Zamboni, NEBDAC Advocacy Coordinator.
Posted: November 27, 2024. This article was originally shared in our Winter 2024 Newsletter.
Many associate NEHA’s advocacy work with visible achievements, like establishing March as Bleeding Disorders Awareness Month, coordinating New England’s participation in Washington Days, and advocating for state bills that impact our community like banning accumulator adjusters and creating rare disease councils. However, a crucial task we undertake every year is engaging with state Drug Utilization Review (DUR) Boards and Pharmacy and Therapeutics (P&T) Committees. Though less publicized, these panels, typically comprising physicians, nurses, and pharmacists, play a critical role in shaping Medicaid formularies and preferred drug lists—which are key to determining which treatments patients can access in their state.
In 1993, legislation required states to establish DURs and P&Ts to support Medicaid by reviewing and approving drug use criteria, applying these criteria, reporting results, and recommending educational interventions. Like private insurers, state Medicaid programs must evaluate the impact of covering new treatments, assessing costs, effectiveness, and safety—and these committees help them accomplish this goal.
DUR and P&T boards vary by state and may include additional members, like health finance experts, medical billers, social workers, or lawyers. These boards assess new medications to determine which should be included in state Medicaid programs. Both models evaluate clinical evidence, research, expert opinion, FDA approval, and increasingly, patient experience. Some also consider cost-effectiveness and reimbursement impacts, meeting quarterly, monthly, or as needed.
New treatments continually emerge, and decisions about them can profoundly impact patient care. To support informed decisions by DUR and P&T boards, and to ensure patients with bleeding disorders continue to have access to the treatments they need, NEBDAC State Leads closely monitor their actions, attend meetings, and submit educational letters to board members across New England. When bleeding disorder treatments are on the agenda, NEBDAC ambassadors attend to share personal stories, underscoring the critical need for patient access to these essential medications.
Mike Dowling serves as a NEBDAC State Lead in Vermont. He regularly attends these important meetings to share his story and stay aware of changes that impact the medications used in bleeding disorders community. To explain his role with these committees in Vermont, Mike said:
“Vermont, like many other states, uses a third-party for-profit review company to help inform their decision. The Committee members typically then approve the recommendations made by the review company. While this DUR Review Board is technically just making Formulary decisions for Medicaid, most, if not all, of the other private for-profit commercial insurers honor or abide by this same list of “Preferred” and “Non-Preferred” prescription pharmaceuticals. So, these decisions made at P&T and DUR hearings usually end up affect everyone in the State, not just people with Medicaid. This is why it is important for our community members to participate in these meetings—to show that we depend on these medicines.”
If you are interested in working with NEBDAC on important advocacy initiatives, or volunteering to do other advocacy-related activities, visit www.nebdac.org.