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What is Managed Care Pharmacy?
Developed by AMCP Membership Committee Updated: February 2016 Updated January 2016
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Agenda Introduction to AMCP Managed Care Pharmacy Overview
Roles of Pharmacists in Managed Care Pharmacy AMCP Student Pharmacist Membership
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Introduction to AMCP
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Vision Statement Mission Statement
Managed care pharmacy improving health care for all Mission Statement Empower its members to serve society by using sound medication management principles and strategies to improve heath care for all Core Values In anticipating and serving the needs of our members in the provision of high quality health care, AMCP embraces the following core values: Credibility Transparency Collaboration Innovation
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Managed care Pharmacy overview
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Goals of Managed Care Prevention of disease
Focus on wellness and enhanced quality of life Improved clinical outcomes Quality and accessibility of health care Cost containment Goals differ from indemnity. Healthcare resources are not unlimited. Must have prudent use of available resources.
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What is Managed Care Pharmacy?
Managed care pharmacy focuses on managing medication specific outcomes in a way that drives down the total cost of care and improves the overall wellbeing of the patient. Managed care pharmacy organizations cover populations of people – pharmacists in managed care pharmacy have the ability to impact the care of millions of patients.
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The Players in Managed Care Pharmacy
Lot of players in managed care pharmacy – work together to reach the goals of managed care pharmacy
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Managed Care Pharmacy Tools
Formulary development with P & T Committees Medication Therapy Management Prescription Drug Monitoring programs Drug Utilization Review Utilization management: prior authorizations, quantity limitations, and step therapy Preferred & exclusive networks Mail order pharmacy Specialty pharmacy Mention they can download tools brochure
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Roles of pharmacists in managed care organizations
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Pharmacists in Managed Care Pharmacy
Over 18,000 pharmacists working for health plans and pharmacy benefit management companies Ensure the pharmacy benefit plan provides individual patients with medications that are: Clinically appropriate Cost-effective Delivered through the appropriate channel Source: Estimates as of 2013
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Drug Distribution and Dispensing
Pharmacists manage drug distribution process through four different approaches: Community Pharmacies – MCOs contract with broad-based networks of participating pharmacies Manage the pharmacy network Perform drug utilization reviews (DUR) Managed Care Organization Operated Pharmacies In-house pharmacy owned by the managed care organization to provide enhanced pharmaceutical services
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Drug Distribution and Dispensing
Mail Order and Online Services Some Managed Care Organizations own or contract with mail order pharmacies Manage services to ensure quality Collaboration with physicians and other healthcare professionals Work with prescribers to ensure the medications prescribed are: Eligible for Coverage Clinically Appropriate Cost Effective
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Patient Safety Pharmacists help ensure patient safety by:
Analyzing prescription claims Reviewing prescription use patterns Educating prescribers about best practices
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Patient Safety Programs/Tools
Drug Utilization Review (DUR) programs identify potential prescription-related problems Drug/drug interactions Duplication of therapy Known allergies Under- or overdosing Potentially inappropriate therapy
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Patient Safety Program/Tools
Fraud and Abuse Programs Review key drug classes Monitor for patterns of inappropriate use Prior Authorization (PA or “Prior Auth”) Programs Approval process to encourage proper use of medications Discourages inappropriate prescribing of medications PA—also used as a cost control tool
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Patient Safety Programs/Tools
Monitoring Programs Lab-based monitoring Ensure medications are prescribed safely and used appropriately Assess response to therapy Monitor medication adherence Screen for potential fraud, waste, and abuse Promote optimal patient outcomes
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Clinical Program Development
To enhance patient care, particularly for those with chronic conditions, pharmacists design clinical programs to: Use evidence-based research data to create disease-management and medication therapy management programs Encourage appropriate prescribing and proper use of medications Promote use of cost effective therapies to benefit both patients and payers Improve health and quality of life for population under their care
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Communication with Patients, Prescribers, and Pharmacists
Pharmacists design and use communication protocols to facilitate exchange of necessary information: Notify prescribers of drug safety alerts and prior authorization requirements Educate patients on their disease state and medications Provide pharmacies information regarding benefit parameters
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Plan Benefit Design Pharmacists collaborate with other healthcare professionals to design effective benefit structures that serve a population’s needs: Formulary Plan Design Pharmacy network Utilization management Patient cost share Use of generic drugs
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Business Management Pharmacists contract with employer and health plan clients, pharmacies, and manufacturers to structure business arrangements that: Allow their clients to customize clinical and reporting requirements Negotiate with manufacturers for discounts on drug prices Establish networks of pharmacies
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Cost Management Pharmacists help their clients (employers, HMOs, trust funds, Medicaid, etc.) evaluate and improve their pharmacy benefit: Encouraging providers to prescribe cost effective treatments Integrating improvements with healthcare delivery Introducing system interventions Using data to identify adherence and non-adherence Ensuring a scientific evaluation of cost
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AMCP Student PHARMACIST membership
Opportunties with your AMCP membership
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Membership Advantages
General Membership Benefits Valuable Resources Access to the Journal of Managed Care & Specialty Pharmacy (JMCP) and Daily Dose news briefings Monthly Webinars Nexus and Annual Meeting & Expo Student Pharmacist Benefits Student pharmacist-specific programming Conferences Webinars Managed Care Pharmacy Residency Showcase Student Pharmacist Resource Center: November we will be having an interview skills webinar
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Opportunities with your local chapter
Get involved with your AMCP Student Pharmacist chapter!! Participate in chapter programs, activities, and committees AMCP Foundation P&T Competition Networking and Professional Events Chapter specific events Serve as an elected chapter officer If they don’t have a chapter – contact AMCP about forming one
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Student Involvement Varies by Year
1st year Attend events hosted by your AMCP student pharmacist chapter Volunteer for an AMCP Chapter committee 2nd year Run for chapter officer Apply for Managed Care Summer Internships 3rd year Participate in the AMCP Foundation P&T Competition Apply for national AMCP Committees 4th year Attend AMCP Nexus Managed Care Pharmacy Residency Showcase to find a managed care residency program Be proactive, volunteer for committees Attend meetings to meet managed care professionals and learn about the many different opportunities within managed care pharmacy
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How to Make the Most of Your Membership
Start collecting business cards! Build a relationship with your local AMCP Diplomat Contact local Managed Care Pharmacy Professionals Network, Network, Network 2 National Meetings - AMCP Nexus and Annual Meeting & Expo Student-specific educational sessions and webinars Local student pharmacist run conferences Be There! AMCP chapter opportunities No chapter? Create one! National AMCP Volunteer and Committee Opportunities Volunteer Contact: Ashley Lanham for details on how to create a student chapter!
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Thank you! Special thanks to AMCP Past-President Gene Reeder, AMCP Staff Betty Whitaker and Susan Noell, and the Membership Committee Members: Barbara Hamer, Carrie Armstrong, Donna Bell, Jasmine Knight, Karen Goolsby, Kim Forester, and Vimal Reddy
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Thank you to AMCP member Nisreen Shamseddine for reviewing this presentation for 2016.
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