Managed care is a method for optimizing patient health using evidence-based medication strategies. The purpose is to enhance the quality of healthcare for all patient populations while reducing the cost.

Managed care is beneficial for patients and the health care system when used appropriately. Although certain aspects may be tedious and limiting, managed care plays a crucial role in gearing patients towards using the most cost-effective services and care. As managed care continues to develop, healthcare professionals and health plans must continue to collaborate with each other to ensure upward trends in the improvement of quality of care, patient safety, and beneficial clinical outcomes.

Recently, we’ve seen a growing trend to have more pharmacists working in managed care. As the most accessible healthcare provider, pharmacists in all areas of the healthcare industry would benefit from knowing more about managed care and health plans to better assist patients.

The Role of the Pharmacist in Managed Care

Pharmacists have always been a liaison between the patient, their providers, and their health care plans. Pharmacists are crucial in ensuring efficacy in therapeutic management of patients, as well as reducing costs for all stakeholders.

The Academy of Managed Care Pharmacy summarizes the role of managed care pharmacists as designing and implementing:

• Quality assurance programs to enhance patient safety and service

• Medication management programs that improve patient health

• Drug benefit programs to ensure broad patient access to needed medications

• Fraud, waste and abuse programs to decrease misuse of medications and drug diversion

The Academy of Managed Care Pharmacy states that Pharmacists in managed care roles are involved in developing formularies, medication therapy management, prescription drug monitoring programs, drug utilization review, and the development of utilization management tools like prior authorizations, quantity limits, and step therapy.

Additionally, pharmacists collaborate with other health care professionals to design plans that serve specific population’s needs, like Medicare and Medicaid. Pharmacists also play a critical role in the development of patient centric clinical programs to enhance health outcomes. By using evidence-based research data, pharmacists contribute to keeping the plan’s coverage of drugs and services updated. Pharmacists also encourage and educate other health care professionals about the appropriate use of medication and prescribing practices which leads to the benefit of both the patients’ care while also keeping unnecessary medical spending low. Another service provided by pharmacists is Medication Therapy Management, or MTM, which gives pharmacists the opportunity to meet with patients to review their medication regimen to identify any potential medication related problem. The involvement of pharmacists in identifying unnecessary or inappropriate therapies increases the efficiency of the healthcare system.

Formulary Management

Pharmacists are medication experts who are great assets in designing benefit plans for patients. These benefit plans take several things into account including formulary, pharmacy network, utilization management, member cost share, and the use of generic medications.

Pharmacists that are part of the Pharmacy and Therapeutics (P&T) committees can aid in deciding which medications should be placed on the formulary based on evidence of the medication’s safety and effectiveness. This improves the use of cost-effective treatments, allowing for optimization of patient care.

Ensuring Patient Outcomes

Pharmacists can also participate in clinical program design. Clinical programs are created using evidence-based research. These programs ensure appropriate medication prescribing and use, promotes the usage of cost-effective regiments, and improved quality of care. The clinical programs can also help identify potential causes of medication non-adherence.

Outreach programs can be designed by pharmacists and are used as a means of communication between prescribers, patients, and pharmacies. Pharmacists are able to alert pharmacies of benefit parameters and prescribers of drug safety concerns, requirements for prior authorizations, and the most effective therapies to be used. Through these outreach programs, pharmacists can educate patients about their disease states and the therapeutic agents they are receiving. Pharmacists can use their expertise to conduct drug utilization reviews (DUR) and fraud/abuse programs, both of which are used to promote patient safety. The DUR programs identify any known allergies, therapeutic agent duplication, dosing errors, drug-drug interactions, and potentially inappropriate medication.

By designing and being a part of these various programs, pharmacists can optimize patient care. Most notably, services like medication therapy management allow pharmacists to be directly involved in patient care and help patients stay engaged in their course of therapy. Studies have shown that MTMs have increased patient adherence to medications, resolved medication-related and decreased overall cost of healthcare. By keeping in close contact with the patients, pharmacists can identify unnecessary or ineffective drug therapies, reduce polypharmacy, and increase overall efficiency of the healthcare system. If the patient is well managed in the outpatient setting, healthcare dollars can be saved by preventing any high-cost services such as hospitalization. In addition, managed care pharmacists strive to increase accessibility to healthcare and promote enhanced quality of life.

Benefit Design

Pharmacists also play a crucial role in the development of a managed care plan. Annually, the plans are reviewed and updated to meet the most current clinical practice and guidelines. In this process, managed care pharmacists assist with updating the plans formulary, and assuring the plan is compliant to the current guidelines and CMS requirements.

When designing a managed care plan, it is crucial that the organization has accurate, most up-to-date clinical knowledge and skills to ensure that their patients are offered the best quality care at a financially adjusted price. Throughout this process, pharmacists have been of great value.

In pharmacy education, there is a focus on understanding the health economics and outcomes involved in using one drug product over another. Determining the clinical benefits and risks as well as understanding the cost component in choosing a therapy is inherent in the pharmacist role. Pharmacists in all roles, not just managed care, use these skills to help reduce costs and help them see the desired outcomes.

Managed care pharmacists often contribute in the development of the criteria for prior authorization surrounding expensive or brand medications or upholding the policies for their beneficiaries through claim review.

Becoming a Managed Care Pharmacist

At first glance, managed care organizations do not seem like a career option for pharmacists but there is a demand for these professionals in this field. Understanding more about managed care and utilization management is pivotal for being an effective managed care pharmacist.

As a Prior Authorization Certified Specialist, you can reinforce your experiences in improving patient outcomes with getting a larger understanding of managed care and utilization management processes that are frequent with insurance plans and pharmacy benefit managers.

The Prior Authorization Certified Specialist program is an accredited, self-paced, online certification program for professionals who navigate the prior authorization and utilization management processes of managed care. Become an expert in prior authorizations, managed care, federal and commercial health insurance, drug tiering, step therapy, medical necessity, quantity limits, and more.