Managed Care Presentation for Students
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Managed Care Presentation for Students
- 1. Managed Care Pharmacy Dan Goldman, PharmD Clinical Pharmacy Coordinator SelectHealth December 10, 2010
- 3. National professional society dedicated to the concept and practice of pharmaceutical care in managed health care environments
- 4. AMCP's mission is to promote the development and application of pharmaceutical care in order to ensure appropriate health care outcomes for all individuals
- 5. AMCP’s purpose is to represent the views and interest of managed care pharmacy
- 7. AMCP's vision is managed care pharmacy improving health care for all
- 10. Improve quality and accessibility of health care
- 11. Improve outcomes and overall quality of life for patients
- 14. Pharmacy Benefit Management (PBM) firms
- 16. Specialty Pharmacy Providers (SPP)
- 17. Retail Pharmacy
- 19. Administer medical and pharmacy benefits
- 20. Roles of a pharmacist in a health plan
- 21. Benefit development and administration
- 22. Counseling
- 24. Drug utilization review (DUR)
- 27. Drug information
- 29. Product contracting & negotiations
- 30. Understanding product value & positioning
- 31. Discussions on formulary placement
- 32. Education – disease, product
- 33. Development of treatment algorithms
- 34. Disease management program support
- 35. Pharmacoeconomic modeling and outcomes research programs
- 36. Medical information to customers (patients, physicians, health plans, etc.)
- 38. Roles of a pharmacist in Industry
- 41. Drug Safety
- 43. Health Economics and Outcomes Research
- 47. Provide clinical and distribution services to patients in the management of chronic, rare, or complex conditions
- 48. Specialty medications require tailored patient education to ensure safe and cost-effective use, patient-specific dosing, close patient monitoring, and/or special handling
- 49. Medication therapy management and adherence management
- 50. Education, support, and coordination of care
- 51. Roles of a pharmacist in a specialty pharmacy
- 52. Specialty Pharmacy distribution and dispensing
- 53. Perform DUR and other utilization management programs
- 56. Process and deliver prescriptions
- 57. Respond to insurance rejections
- 58. Contracting to become part of a insurer network
- 59. Functions of Hospital Pharmacist
- 60. Provide feedback to P&T committee
- 62. Evaluate performance of managed care organizations (MCOs)
- 63. Provide client support for decision making when choosing outside health vendors or clinical programs
- 64. Role of a Pharmacist in Consulting
- 66. Formulary
- 71. Pharmacy & Therapeutics (P&T) Committee
- 72. Pharmacist reviews, presents, makes recommendations
- 73. Physicians Vote
- 76. Sample PA
- 77. Step Therapy
- 78. Quantity Limits
- 79. Tier levels
- 80. Tier 1 – generic
- 81. Tier 2 – preferred brand
- 82. Tier 3 – non-preferred brand
- 83. Other edits
- 86. Sample PA
- 87. Step Therapy
- 88. Quantity Limits
- 89. Tier levels
- 90. Tier 1 – generic
- 91. Tier 2 – preferred brand
- 92. Tier 3 – non-preferred brand
- 93. Other edits
- 95. Medication Management Agreement (MMA)
- 98. Dossiers
- 102. Account management
- 103. Sales
- 104. Marketing
- 107. Consulting
- 109. Government
- 110. Drug Information
- 114. Positive work ethic
- 117. Academic knowledge
- 119. Innovator
- 120. Adaptable
- 124. Varying length and locations
- 125. Leadership
- 127. National Committees
- 129. One- or two-year postgraduate training programs
- 130. Development of advanced knowledge and skills distinct to the managed care environment
- 132. Broadening oneself in a pharmacy niche
- 133. Staying up-to-date with place-in-therapy of new drugs and pipeline agents
- 134. Exposure to operational, business and clinical aspects of pharmacy
- 135. Provides a competitive advantage in the job market
- 136. Greater potential for upward career growth and new career optionshttp://www.ashp.org/Import/ACCREDITATION/ResidentInfo/WhydoResidency.aspx
- 138. Attractive work/life balance, including travel & education
- 139. Zero to minimal dispensing role/staffing component
- 140. Develop career plan and professional vision
- 143. Need to postpone financial rewards of a pharmacist’s salary
- 144. Limited direct face-to-face patient interactions (depending on organization), more patient-population directed interactions
- 145. Individuals unfamiliar with managed care may view the business trainings as less “clinical”
- 146. Potential relocation need due to limited availability of positions
- 148. Academy of MC Pharmacy (AMCP) school & national chapters
- 150. Internships (summer or throughout school year)
- 151. Shadowing opportunities with practitioners
- 152. Be visible
- 153. AMCP, ASHP or local residency program showcases/career fairs
- 154. Utilize resources
- 156. Current information about managed care
- 157. Career development
- 159. National conferences
- 160. Subscriptions to multiple AMCP resources
- 161. AMCP/FMCP/AllerganManaged Care Pharmacy Summer Internships
- 163. Duquesne University
- 165. Howard University
- 168. Mercer University
- 173. Palm Beach Atlantic University
- 174. Purdue University
- 175. Rutgers University
- 176. Samford University
- 178. Touro University - California
- 179. University of California at San Francisco
- 182. University of Illinois at Chicago
- 185. University of Missouri - Kansas City
- 188. University of Southern California
- 189. University of the Pacific
- 190. University of the Sciences in Philadelphia
- 191. University of Utah
- 194. www.amcp.org
- 195. Content: ASCENT Center – managed care resources, residency directory, rotation directory
- 196. American Society of Health Systems Pharmacists (ASHP)
- 197. www.ashp.org
- 199. The A.S.C.E.N.T. Student Center has links to the following:
- 200. Publications and Resources for Students
- 201. Glossary of Managed Care Pharmacy Terms
- 202. List of Managed Care Residencies
- 203. List of Managed Care Rotations
- 204. List of Pharmacy Schools in the United States
- 205. List of AMCP Student Chapters
- 207. Student Pharmacist Committee Roster
- 209. Summer Internships
- 211. A Good Case for the Necessity of Managed Care
- 212. “The Truth About the Drug Companies” by Marcia Angell, MD, former Editor-in-Chief of NEJM
- 215. Questions?
Editor's Notes
- SelectHealth is a non-profit health insurance plan that is part of Intermountain Healthcare.I’ll be lecturing you today on this topic, but I also have somewhat of a vested interest in getting you excited about managed care pharmacy, as I recently became the Academy of Managed Care Pharmacy Diplomat to your USN. Much of this lecture material is provided by AMCP.I am going to attempt to relate managed care back to you in the most relevant way possible while still providing a broad overview of the topic, and at the end I will explore educational opportunities and career paths in managed care.
- I realize this is all somewhat convoluted. I like to think of managed care pharmacy as guiding drug utilization towards safety, efficacy, and cost-effectiveness.
- Health plans…Insurers:United Healthcare, Aetna, BCBSIntegrated health plans: Kaiser Permanente, SelectHealth/Intermountain Healthcare
- Some of you might be of the belief that you are going to work as a retail pharmacist or hospital pharmacist and that managed care will have no impact on your daily responsibilities.Retail pharmacy is an important tool in making managed care work. What do you do when a patient’s drug is rejected at the pharmacy? Tell them sorry? Or help resolve the issue based on the rejection message? “Ma’am/Sir, this drug requires a prior authorization from your insurance…I will contact your physician to arrange this”As far as hospital pharmacy is concerned, you better believe that any hospital pharmacist will want to be highly involved in helping to craft a hospital formulary when a new drug comes out related to their specialty. For example, a pharmacist that runs a coumadin clinic would be interested in the upcoming decisions that the hospital P&T committee will make regarding Pradaxa and all the new anticoagulants.
- PBMs = ESI, MedCo, CaremarkBasically an insurer but only cover the pharmacy portion of healthcare.They have been highly criticized lately in part due to their high profits. They do, however, provide valuable services and do a decent job of controlling pharmacy costs, especially in relation to medical costs.
- In general, the main responsibility of a managed care pharmacist is managing the formulary. A formulary is essentially a comprehensive list of drugs and their coverage status.The primary strategic mechanism for management is through the use of a P&T committee that reviews individual drugs and drug classes. It should be noted that not all P&T committees work the same way, so what I’m providing here is an example of my company’s operating principles.Example: Tobi presentation and outcomeInjectables: A P&T sub-committee for less utilized, but often higher cost injectable or specialty drugs that might require more managementKrystexxa – presented on it, recommended PA’ing it due to safety concernsand potential for inappropriate or early use on this ~$60k/year drugOf course, once decisions are made, then they need to be put into operation…
- ST – PPI exampleQL – If a drug is dosed once a day, we’ll typically put a quantity limit of 30/month. We’re never more strict than the labeled dosing and are often more lenient.Tier levels: Tier 1 is lowest co-pay and tier 3 is highest co-pay Several studies have shown that co-pay amount affects utilization/compliance A highly aligned physician network will fall in line with a clinically appropriate formulary
- This is an actual PA that we utilize. All of our PAs are public documents that we make available on our website.Explain criteria…
- ST – PPI exampleQL – If a drug is dosed once a day, we’ll typically put a quantity limit of 30/month. We’re never more strict than the labeled dosing and are often more lenient.Tier levels: Tier 1 is lowest co-pay and tier 3 is highest co-pay Several studies have shown that co-pay amount affects utilization/compliance A highly aligned physician network will fall in line with a clinically appropriate formulary
- There are managed care pharmacists who just participate in MTM or who just review PAs. Some people enjoy that kind of specificity. I personally enjoy getting to work on a vast array of projects, which is something that my current position provides.
- This is my attempt to get you excited about all the possibilities and career opportunities. Managed Care = explain my job and talk about all the pharmacists’ roles at SHPBMs = MCO but only relates to the drug benefitConsulting = HealthStrategy, Solid Benefit GuidancePharma = Account Managers, MSLs, Health Outcomes Researchers, etc …for those of you interested in working for PHRMA, previous experience in managed care is a good foot in the doorGovernment = FDA and other agenciesMedical writing = Journal editors No patient interaction, but these are highly influential positions – you really make a difference as a whole.Challenging, lots of complex problem solving and strategic planning, lots of room for personal development, encourages constant learning about new drugs because you’re in charge of managing their utilization from the get go, but also provides reinforcement of your knowledge base. Also, the market demand for managed care pharmacists is healthy according to my recent experience. That might not continue to be the case in community and hospital pharmacy.Salaries because pharmacy students tend to care about that – starting salary for a managed care pharmacist is typically between that of a hospital pharmacist and a community pharmacist, but…One of the best parts about a managed care career path is that though you enter as a well-paid professional employee, there is still a great potential for advancement after that.See “Mapping Your Career in Managed Care Pharmacy” on student ASCENT Centerhttp://www.amcp.org/amcp.ark?pl=AE2A36B2
- These are some characteristics of an ideal application. To these I would add: Self-motivated. Well-rounded. Flexible. Dedicated to life-long learning. Possibly has some business acumen. I’m told you have a dual PharmD/MBA program – so graduates with this credential would possibly be strong candidates.Common characteristics programs are looking for in a good resident candidate – someone who displays the following:The program can identify these characteristics about the applicant through your cover letter, recommendations, college transcript, resume/curriculum vitae, onsite interviews and even through program communication with your previous advanced professional pharmacy experience preceptors! Active participation in available managed care opportunities throughout one’s pharmacy education places an applicant in a competitive advantage compared to other applicants
- I mentioned the AMCP/FMCP/Allergan, Inc Specialized Summer Internship Program in Health Outcomes. Applications are being accepted until February for those interested, but as I understand it your curriculum goes through the summer. I had the same issue that prevented me from participating in internships as a student.A lot of people who are interested in pharma feel that a fellowship in health outcomes or pharmacoeconomics is the best path to take.Much of the rest of this information we are going to fly through. I’ve included it here more as a reference for you if you’ve been intrigued by what you’ve heard so far.
- Do you have to do a residency for most of the career opportunities related to managed care? For a new graduate looking to enter this field, I would say absolutely. Don’t let that immediately discourage you though. As someone who just completed a managed care residency this past summer, I can wholeheartedly recommend this path.The listed benefits highlight what students who are interested in managed care often associate with managed care pharmacy. If a student who is unsure about managed care pharmacy is excited about the listed benefits– perhaps this hints at a “good match” for this individual and a managed care residency experience. Additional details on each of the bulleted points mentioned on the slide:1. Often careers place the pharmacist in a particular career path based on their job experience. With managed care residency, you have training in managed care but managed care experience is an asset for other career paths beyond managed care; previous MC residents have continued into industry, management, institutions, etc2. In no other career will you be trained on how to stay on top of new drug developments, as part of your job. It is a habit that would benefit any pharmacy professional committed to successful life-long learning. A residency will focus on building this skill.3. In MC, you get a well-rounded experience, including exposure to “management” for those interested in that career ladder.4. See bullet 1 above.5. See bullet 3 above and training that would place you in a clinical account manager role that is not available to newly graduated pharmacists without a managed are residency background.Great videos on general residency programs available on ASHP web site - http://www.ashp.org/Import/ACCREDITATION/ResidentInfo/WhydoResidency.aspxTopics include (on a 15 minute video - http://www.ashpmedia.org/video/resident/Why%20a%20Residency%20Full.html): Why should I do a residency What is a residency The benefits of doing a residencyWhen should you start thinking about doing a residencyThe final steps
- The listed benefits highlight what students who are interested in managed care often associate with managed care pharmacy. If a student who is unsure about managed care pharmacy is excited about the listed benefits– perhaps this hints at a “good match” for this individual and a managed care residency experience! Keep in mind that new pharmacy graduates may not necessarily be concerned about these factors early in their career; a way to explain the importance of these benefits is to provide a personal story linked to the value of these benefits as you love along in your career!
- Students are often unaware of residencies in managed care pharmacy due to limited exposure during their academic career. Since these residencies are significantly different compared to institutional and community-based residencies, it is important that the student receives enough education about these training experiences so that they are able to make an informed decision.Explanations to the bullets on this slide:1. As with any residency training, the salary is significantly less than you would make working as a full-time pharmacist elsewhere.2. A MC residency is not ideal for individuals looking for direct patient care; however, MC does involve a direct impact on patient care which is often just a rewarding. Residents and MC pharmacists are often able to continue a part-time/per diem staff pharmacist position concurrently.3. MC pharmacists make use of drug literature skills and clinical decision-making skills on a day-to-day basis. Everything is evidence-based.4. Positions are often available but not easily identified based on unique advertising venues and different settings qualified as MC positions. However AMCP has a link to postings for MC positions and internships.5. Limited rotation experiences but AMCP now hosts a webpage where schools advertise available internships.
- The AMCP student ASCENT center provides student internship opportunities as well as reading materials to promote awareness of managed care specifically designed for students.ASCENT stands for “Awareness/Access, Shadowing, Connectivity, Encouraging, Navigating, Training” used to describe resources that AMCP provides to budding pharmacists considering a career in managed care. Please visit the AMCP site for a compete definition of this acronym.
- Is anyone here a member of this organization?
- Since there are a number of resources on the provided links, speakers should visit these sites and possibly open a browser during the lecture to walk the audience through the most beneficial areas on the site (as suggested on the slide above). Perhaps a link to those specific useful pages can be provided as a separate handout to the class).
- Provides a list of managed care rotations and residencies
- This is a relatively light read that provides some good background of drug development over the past 20 years.
- I plan to be engaged in future USN events including career fairs and possibly the formation of a student chapter.Please contact me if you have any interest:in shadowing for a day at my organizationsetting up a rotation with us (advanced rotations only)joining AMCPstarting an AMCP student chapteror just simply learning more about the topic. *If you do decide to join AMCP, please list me as your referring member (no, I don’t receive compensation for referring members). I believe membership is $35/year for students. This is well worth it, especially since you can then attend our state affiliate meetings, which provide you with a gourmet meal.