Managed Care Pharmacy
Increasingly, pharmacists are employed in various capacities within managed care organizations (MCOs). Managed care is a system designed to optimize patient care and outcomes and foster quality through greater coordination of medical services. MCOs incorporate pharmaceutical care which strives to improve access to primary and preventive care and ensure the most appropriate and effective use of medical services in the most cost-effective manner.
The number of individuals enrolled in managed care programs has risen dramatically in recent years. At the end of 1995, it was estimated that more than 130 million individuals in the U.S. received health care services through some form of managed care. As managed care continues to assume a larger role in our health care system, opportunities for pharmacists practicing in these types of settings are expected to grow. Areas in which managed care pharmacists can play a role include:
I. Practice Guidelines and Protocol Development
Managed care pharmacists often work directly with physicians and other caregivers to determine which medical treatments, including which drug therapies, are most effective in enhancing patient outcomes. That can involve regularly reviewing medical literature to determine which medications are the safest and most effective for treating certain diseases, gathering data from the plan’s patient population, and performing analyses based on that research.
II. Drug Utilization Review / Drug Use Evaluation
Managed care pharmacists review drug utilization to determine which patients and prescribers are using particular medications. This allows the pharmacist to determine whether some drugs are inappropriately prescribed or used. With this knowledge in hand, the pharmacist and other care providers can then actively intervene in the patient’s care process to assure better outcomes.
III. Care Management Programs
Often called Disease Management Programs, these programs involve having pharmacists, physicians, case managers, and other caregivers work together to effectively manage and coordinate the overall care of patients who are at high risk of serious complications because of certain disease states. For example, a care management program might identify all diabetic patients within a certain plan population, and then place special emphasis on making sure those patients receive regular education and counseling about their disease, including how and when to take their medications. Pharmacists might then interact with the patient and the patient’s physicians on a regular basis to try to keep the patient as healthy as possible. Other responsibilities in the managed care environment can include:
- Contracting with local pharmacies (to develop networks to serve plan members);
- Contracting with pharmaceutical manufacturers (to receive rebates on prescription drug products and other value-added services);
- Claims processing (so patient-prescriber data can be transmitted electronically to assure accurate claims payment and provide information to assist with clinical functions such as drug utilization review); and
- Developing and managing the plan’s approved drug therapy options.