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What is Managed Care Pharmacy? Developed by AMCP Membership Committee 2014-15 Agenda Introduction to AMCP Managed Care Pharmacy Overview Roles of Pharmacists in Managed Care Pharmacy AMCP Student Pharmacist Membership ©2014 Academy of Managed Care Pharmacy INTRODUCTION TO AMCP • Vision 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 ©2014 Academy of Managed Care Pharmacy MANAGED CARE PHARMACY OVERVIEW 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 ©2014 Academy of Managed Care Pharmacy 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. ©2014 Academy of Managed Care Pharmacy The Players in Managed Care Pharmacy ©2014 Academy of Managed Care Pharmacy 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 www.amcp.org/mcptools ©2014 Academy of Managed Care Pharmacy ROLES OF PHARMACISTS IN MANAGED CARE ORGANIZATIONS 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 ©2014 Academy of Managed Care Pharmacy Drug Distribution and Dispensing Pharmacists manage drug distribution process through four different approaches: Community Pharmacies – MCOs contract with broadbased 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 ©2014 Academy of Managed Care Pharmacy 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 ©2014 Academy of Managed Care Pharmacy Patient Safety Pharmacists help ensure patient safety by: • Analyzing prescription claims • Reviewing prescription use patterns • Educating prescribers about best practices ©2014 Academy of Managed Care Pharmacy 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 ©2014 Academy of Managed Care Pharmacy 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 ©2014 Academy of Managed Care Pharmacy 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 ©2014 Academy of Managed Care Pharmacy 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 diseasemanagement 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 ©2014 Academy of Managed Care Pharmacy 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 ©2014 Academy of Managed Care Pharmacy 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 ©2014 Academy of Managed Care Pharmacy 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 ©2014 Academy of Managed Care Pharmacy 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 ©2014 Academy of Managed Care Pharmacy AMCP STUDENT PHARMACIST MEMBERSHIP Membership Advantages General Membership Benefits – Valuable Resources • Access to the Journal of Managed Care & Specialty Pharmacy (JMCP) and www.amcp.org • Daily Dose email 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: www.amcp.org/studentcenter ©2014 Academy of Managed Care Pharmacy 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 ©2014 Academy of Managed Care Pharmacy Student Involvement Varies by Year • Attend events hosted by your AMCP student pharmacist chapter 1st year • Volunteer for an AMCP Chapter committee • Run for chapter officer 2nd year • Apply for Managed Care Summer Internships • Participate in the AMCP Foundation P&T Competition 3rd year • Apply for national AMCP Committees • Attend AMCP Nexus Managed Care Pharmacy Residency Showcase 4th year to find a managed care residency program ©2014 Academy of Managed Care Pharmacy How to Make the Most of Your Membership Network, Network, Network • Start collecting business cards! • Build a relationship with your local AMCP Diplomat • Contact local Managed Care Pharmacy Professionals Be There! • 2 National Meetings - AMCP Nexus and Annual Meeting & Expo • Student-specific educational sessions and webinars • Local student pharmacist run conferences Volunteer ©2014 Academy of Managed Care Pharmacy • AMCP chapter opportunities • No chapter? Create one! • National AMCP Volunteer and Committee Opportunities How to Ask A Question Type your question in the ‘Questions’ area ©2014 Academy of Managed Care Pharmacy 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