Managed Care Pharmacy

Dan Goldman, PharmDClinical Pharmacy Coordinator

SelectHealth

December 10, 2010

Academy of Managed Care Pharmacy

• Founded in 1989• National professional society dedicated to the concept and practice of

pharmaceutical care in managed health care environments• AMCP's mission is to promote the development and application of

pharmaceutical care in order to ensure appropriate health care outcomes for all individuals

• AMCP’s purpose is to represent the views and interest of managed care pharmacy

• AMCP has more than 5,700 members nationally provide comprehensive coverage to over 200 million Americans served by managed care

• Vision Statement – AMCP's vision is managed care pharmacy improving health

care for all

• Mission Statement – AMCP's mission is to empower its members to serve

society by using sound medication management principles and strategies to improve heath care for all

Academy of Managed Care Pharmacy

What is Managed Care?

• An organized health care delivery system with three major goals– Improve quality and accessibility of health care– Improve outcomes and overall quality of life for

patients– Contain medical costs

• Managed care pharmacy – focus is on drug therapy and pharmaceutical care of a population rather than an individual

Key Players in Managed Care

• Health Plans • Pharmacy Benefit Management (PBM) firms• Pharmaceutical Industry• Specialty Pharmacy Providers (SPP)• Retail Pharmacy• Consulting Firms

Health Plans

• Function of a health plan– Administer medical and pharmacy benefits

• Roles of a pharmacist in a health plan– Benefit development and administration– Counseling– Formulary management– Drug utilization review (DUR)– Disease management– Quality improvement– Drug information– Contracting

Pharmaceutical Industry

• Functions of the Industry– Product contracting & negotiations– Understanding product value & positioning– Discussions on formulary placement– Education – disease, product– Development of treatment algorithms– Disease management program support– Pharmacoeconomic modeling and outcomes research programs– Medical information to customers (patients, physicians, health plans, etc.)– AMCP Product dossiers

• Roles of a pharmacist in Industry– Medical Information Services– Medical Science Liaison– Drug Safety– Regulatory Affairs– Health Economics and Outcomes Research– Sales Representatives– Marketing Managers– Managed Care Account Managers

Specialty Pharmacy Providers

• Functions of the SPP– Provide clinical and distribution services to patients in the

management of chronic, rare, or complex conditions• Specialty medications require tailored patient education to ensure safe

and cost-effective use, patient-specific dosing, close patient monitoring, and/or special handling

– Medication therapy management and adherence management– Education, support, and coordination of care

• Roles of a pharmacist in a specialty pharmacy– Specialty Pharmacy distribution and dispensing– Perform DUR and other utilization management programs– Logistics/operations– Workflow, inventory, and personnel management

Retail/Hospital Pharmacy

• Functions of Retail Pharmacist– Process and deliver prescriptions

– Respond to insurance rejections– Contracting to become part of a insurer network

• Functions of Hospital Pharmacist• Provide feedback to P&T committee• Present to and/or particpate in P&T committee

Consulting Firms

• Functions of Consultants– Evaluate performance of managed care organizations

(MCOs)– Provide client support for decision making when choosing

outside health vendors or clinical programs

• Role of a Pharmacist in Consulting– Assist clients in determining which managed care

organization offers the most appropriate services

Pharmacy Benefit Management (PBM)

• Manage pharmacy benefit programs– Formulary– Generic substitution– Manufacturer discounts/rebates– Prescription co-payments– Drug utilization evaluation

Pharmacist Responsibilities

• Managing the formulary• Pharmacy & Therapeutics (P&T) Committee

• Pharmacist reviews, presents, makes recommendations

• Physicians Vote• Injectable Operations Committee

• P&T subcommittee for injectable and/or specialty drugs

Pharmacist Responsibilities

• Prior authorization• Sample PA

• Step Therapy• Quantity Limits• Tier levels

• Tier 1 – generic • Tier 2 – preferred brand• Tier 3 – non-preferred brand

• Other edits• Dual therapy blocks

Pharmacist Responsibilities

• Prior authorization• Sample PA

• Step Therapy• Quantity Limits• Tier levels

• Tier 1 – generic• Tier 2 – preferred brand• Tier 3 – non-preferred brand

• Other edits• Dual therapy blocks

Pharmacist Responsibilities

• Medication Therapy Management (MTM)

• Medication Management Agreement (MMA)

• Care Process Models (CPMs)

Pharmacist Responsibilities

• Interaction with Pharma• Source of information

• Dossiers• Contracting/Rebates• Methodological Research

• Also done independently

Pharmacist Responsibilities

• Benefit design• Account management• Sales• Marketing• Work with technician phone help desk team

Career Opportunities

• Managed care organization• Pharmacy benefits management• Consulting• Pharmaceutical industry• Government• Drug Information• Medical writing profession

http://www.amcp.org/amcp.ark?pl=AE2A36B2

Characteristics of a MCP

• Demonstrated leadership

• Effective communication skills

• Positive work ethic• Effective time

manager/multi-tasker• Team

Player/contributor

• Academic knowledge• Professional/

Community involvement

• Innovator• Adaptable• Professional behavior• Researcher

Pharmacy Student Opportunities

• Internships– Project-based summer positions– Varying length and locations

• Leadership– Student Chapter Level– National Committees

• Residencies and Fellowships– One- or two-year postgraduate training programs– Development of advanced knowledge and skills distinct to the

managed care environment– Varying locations

MC Residency or Not?

• Benefits– Broadening oneself in a pharmacy niche– Staying up-to-date with place-in-therapy of

new drugs and pipeline agents– Exposure to operational, business and clinical

aspects of pharmacy– Provides a competitive advantage in the job

market– Greater potential for upward career growth

and new career options

http://www.ashp.org/Import/ACCREDITATION/ResidentInfo/WhydoResidency.aspx

MC Residency or Not?

• Benefits– Attractive work/life balance, including travel &

education– Zero to minimal dispensing role/staffing

component– Develop career plan and professional vision– Expand networking opportunities– Loan payment deferral may be an option

during residency year

MC Residency or Not?

• Limitations– Need to postpone financial rewards of a pharmacist’s

salary– Limited direct face-to-face patient interactions

(depending on organization), more patient-population directed interactions

– Individuals unfamiliar with managed care may view the business trainings as less “clinical”

– Potential relocation need due to limited availability of positions

– Professional pharmacy experience may be limited to specific niches

Preparatory Action Steps

• Get involved early on– Academy of MC Pharmacy (AMCP) school & national

chapters– Advanced/introductory pharmacy rotations– Internships (summer or throughout school year)– Shadowing opportunities with practitioners

• Be visible– AMCP, ASHP or local residency program

showcases/career fairs• Utilize resources

– AMCP / ASHP web pages and materials

AMCP Membership Benefits for Students

• Understanding of managed care industry• Current information about managed care• Career development• Networking opportunities• National conferences• Subscriptions to multiple AMCP resources• AMCP/FMCP/Allergan Managed Care Pharmacy Summer

Internships• Leadership positions

AMCP Student Chapters

• Drake University• Duquesne University • Ferris State University • Howard University • Long Island University• Loma Linda University• Mercer University • Midwestern University-Chicago• Nova Southeastern University• Ohio Northern University• Ohio State University • Palm Beach Atlantic University• Purdue University• Rutgers University • Samford University• Shenandoah University• Touro University - California

• University of California at San Francisco• University of Florida• University of Georgia• University of Illinois at Chicago• University of Maryland• University of Mississippi• University of Missouri - Kansas City• University of Oklahoma• University of Pittsburgh• University of Southern California• University of the Pacific• University of the Sciences in Philadelphia • University of Utah• University of Washington• Western University of Health Sciences

Resources

• Academy of Managed Care Pharmacy (AMCP)– www.amcp.org– Content: ASCENT Center – managed care resources,

residency directory, rotation directory

• American Society of Health Systems Pharmacists (ASHP)– www.ashp.org– Content: residency directory, accreditation standards,

educational outcomes/goals/objectives, residency application, National Matching Service rules and requirements

AMCP A.S.C.E.N.T. Program

• A.S.C.E.N.T. represents a six-step strategy to enhance student managed care pharmacy awareness and skills

• The A.S.C.E.N.T. Student Center has links to the following:– Publications and Resources for Students– Glossary of Managed Care Pharmacy Terms– List of Managed Care Residencies– List of Managed Care Rotations– List of Pharmacy Schools in the United States– List of AMCP Student Chapters– Student Chapter Resources– Student Pharmacist Committee Roster

• The A.S.C.E.N.T. Student Center is found on www.AMCP.org

Resources

• Clerkship Rotations• Summer Internships• Residencies and Fellowships• A Good Case for the Necessity of Managed Care

• “The Truth About the Drug Companies” by Marcia Angell, MD, former Editor-in-Chief of NEJM

• Your Colleague/AMCP Diplomat• dan.goldman@selecthealth.org

Acknowledgement

Thank you to AMCP Members Beth Holland, Cathy Moriarty and Glenn Yokoyama for developing this presentation for 2009.

Thank you to AMCP Members Phillip A. Drum, Karen W. Lee, and Ryan Steadman who reviewed

and updated this presentation for 2010.

Special thanks to Amanda Bain, Peter Lee and Annie Rakoczy for their assistance in the development of the presentation.

Questions?