An Introduction to Managed Care Pharmacy
Steph’s Note: This week, piggy backing on our last post about medication access, we’re going to venture into the related world of managed care pharmacy. If you hear that term in conversation, I’m willing to bet a number of you surreptitiously glance at your colleagues or classmates to see if they appear to understand it. You’re probably thinking to yourself, “What exactly is that? I feel like I should know what it is, and everybody else probably does know, so I’m not gonna ask now. It’s too late without looking silly.”
Did they just see a fuzzy alien, or is someone asking them about managed care pharmacy as a career? (Image)
So not the case! Which is why today we have a pharmacist in the thick of managed care pharmacy to shed some light on this career path and clear up what often seems like just the blurred outline of the aliens in the movie Signs.
Angelica (Angie) Asadi completed a PGY-1 managed care pharmacy residency at Kelsey-Seybold Clinic after graduating from the University of Houston College of Pharmacy. Her current role as a health plan pharmacist at KelseyCare Advantage, a 5-STAR Medicare Advantage Plan, is focused on Medicare Part D operations and administration and PBM oversight. Angie has been heavily involved in the Academy of Managed Care Pharmacy (AMCP) on a local, regional, and national level since her time as a first-year student, and she currently serves as the University of Houston Chapter Diplomat, is a Southwest Affiliates Student Advisory Committee member, and is a member of the national AMCP Membership Committee. She also serves as a residency program coordinator for the ASHP/AMCP accredited Kelsey-Seybold Clinic Managed Care Pharmacy Residency program.
Alright, Angie, please debunk the myth!
What is Managed Care [in] Pharmacy?
It’s no exaggeration when I state that this question comes up nearly once a month from various sources. Whether it’s pharmacy students early in their careers or well-experienced pharmacists with a resume to envy, the concept of managed care in the field of pharmacy still seems to be a mystery to most, yet I could not imagine my career as a pharmacist without it.
And that is what has led me to write this today: a love for my career and the impact it has on thousands of lives at once, and the firm belief that the world needs more pharmacists to do what they do best in every aspect of healthcare, including managed care.
After a few years of lecturing on the topic to student pharmacists and pharmacy graduates in a master’s program, I think the best way to introduce you to managed care is through the below questions:
What is managed care?
Managed health care, or managed care, is the concept of coordinating various aspects of health, clinical or financial, to reduce the overall cost of healthcare for both patients and providers.
What does a managed care pharmacist do?
Anything to which they set their mind.
To further elaborate, managed care is a concept of healthcare in the United States that encourages cost management through clinical coordination and decisions. A managed care organization integrates all aspects of health. Think primary care providers, specialty providers, health system services, and pharmacy services - all being provided by the same “brand” or organization to reduce overall cost. There are many types of managed care organizations across the country, on which I will not go into detail, but you can begin to learn more about here.
Managed care tools to reduce health care costs vary from utilization management tools (e.g., every time you heard that a drug got rejected due to needing a prior authorization) to complicated clinical assessments to reduce risk of high-cost disease states through appropriate management of medication therapy. Every step of which usually involves a pharmacist.
Managed care pharmacists may be employed by a managed care organization, such as a health plan, pharmacy benefit manager (PBM), or an integrated health system, such as a diabetes clinic operated in association with a primary care provider team. These roles include but are not limited to:
Formulary management pharmacists
These pharmacists review clinical and/or financial aspects of drugs to determine health plan or health-system coverage provided to patients. Many formulary management pharmacists play a major role in organizational Pharmacy & Therapeutics (P&T) committees, often as the reviewer and presenter of new products.
Coverage determination/prior authorization pharmacists
These pharmacists review coverage determinations, including initial prior authorizations, step therapy requirements, and non-formulary medication requests. They determine whether a patient is eligible for coverage based on their clinical profile.
Clinical pharmacists
Just like non-managed care organizations, clinical pharmacist roles vary greatly within managed care. As an overarching umbrella, they often include virtual outreach to patients since managed care organizations often serve tens or hundreds of thousands of members and want to ensure adequate clinical touch points. These positions often are inspired by social issues and arise from a need to change the healthcare landscape. Some examples of these pharmacist roles include performing medication therapy management (MTM) calls, INR monitoring, post-hospital discharge counseling and medication reconciliation, medication adherence calls, chronic disease state management, and opioid management. These are just a few examples from dozens of clinical pharmacist duties in a managed care organization!
Pharmacy benefit or clinical advisors
This role may encompass many other positions with various titles, in which pharmacists serve as the clinical experts for a diverse array of clinical programs, formulary decisions, or design of health plan benefits. These pharmacists consult clients on numerous aspects of providing health plan services, such as competitive drug copays/coinsurances, appropriate pharmacy networks, supplemental benefit options, and implementation of clinical programs based on the needs of their clients.
Health plan or PBM operations
Similar to other health-system operations roles, these pharmacists utilize their clinical knowledge, along with their managed care knowledge of state and federal regulations, financial implications, and marketplace demand, to operate (or support the operation of) health plans across the country.
Medicare or Medicaid specialists/consultants
Given the strict and closely monitored regulations set by federal and state agencies, pharmacists are used to understand drug related regulations. These pharmacists assist providers, including health plans, pharmacies, prescribers, hospital systems, etc., in implementing procedures and programs in accordance with the provided governmental guidance. This helps the providers to be in full compliance with these organizations for reimbursement, and it can even help them excel in specific rating systems created by the governmental bodies, such as the Medicare star ratings.
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Understanding managed care concepts has allowed pharmacists to work in every single aspect of healthcare in areas, even those you may not otherwise think are a “pharmacist’s job.” Believe it or not, you could be involved in negotiating drug costs as the manufacturer, health plan, or PBM representative. You could help with creating algorithms to identify patients with disease states and medication profiles that could lead to higher rates of hospitalizations. You could take those algorithms to then create new consultation jobs for clinical pharmacists. Seriously, managed care is a vast world of opportunity, where I believe a pharmacist can do anything to which they set their mind.
It’s rare that I go through the aforementioned spiel and don’t get concerned looks or questions such as, “Oh but my school never taught us about managed care, I’m so behind!” Or, “I have no managed care experience…how would I ever get my foot in the door?”
And this is where I let out a maniacal, evil laugh and pity them as I indulge in the magnificence of managed care!!
Just kidding, the managed care rabbit hole is open to all!!
How do I break into a managed care pharmacy career?
The reality is, most of you will not have learned about managed care pharmacy in school, or at least not of all aspects. As the world of health care expands and the significance of pharmacists in the field is increasingly recognized on a daily basis, the world of managed care has quickly adapted to allow for more unique roles for pharmacists. If you’re a student looking to dig further into managed care, your best resource is the Academy of Managed Care Pharmacy (AMCP).
AMCP is THE central resource for student-centered programming, webinars, presentations, pamphlets, internship opportunities, and residency opportunities. (Yes, I said residency opportunities in managed care!) AMCP is a great way to get started building your knowledge base and preparing for the future.
Since managed care is not a significant component of the pharmacy school curriculum, a PGY-1 in Managed Care Pharmacy is often the best way to get exposure to multiple aspects of the field. With a diverse array of accredited and non-accredited (not a bad word in the world of managed care pharmacy) programs, residencies often include various rotations, all unique from other experiences.
Based on the organization type hosting the residency (e.g., health plan, PBM, or both) and the accreditation status of the program, these experiences may vary from all operational rotations to a balanced mix of both clinical and managed care experiences. Managed care operation and administrative type rotations may include insurance benefit design, formulary management, state or federal programs, client management, specialty and retail pharmacy network management, review of coverage determinations, quality measures and accreditation standards, regulatory and compliance, utilization management development criteria, and clinical program operations. Phew, that’s no joke! Comprehensive and certainly filling some holes in the pharmacy school curricula.
Clinical rotations may vary based on the types of programs offered by the residency site, but often include MTMs, disease state management, and patient or drug safety programs.
Now, a moment for the non-accredited status of some managed care residencies and why “non-accredited” doesn’t always automatically mean clicking to the next program. ASHP/AMCP accreditation standards require a certain percentage of direct patient care as a component of the residency curriculum. Depending on your career interests and how much direct patient care you would like to have, this accreditation requirement can assist you in selecting between accredited and unaccredited options. Each of these experiences sheds light on numerous aspects of the field, opening opportunities for potential career paths. It’s more about what your goals are.
If you’re a pharmacy student who does not think they have enough experience or knowledge of managed care to qualify for a residency, please continue reading! For all those who are interested in managed care (at any stage of their career) but don’t believe they are qualified or have the experiences to be competitive, you know more than you may think…
Managed care concepts are embedded into every aspect of health care. Have you…
Assisted a patient by making an alternative, lower-cost drug recommendation to their prescriber?
Helped out by completing prior authorization questions?
Reviewed medication profiles for potential drug-drug interactions at the prompt of an automated message from their insurance?
Completed a drug utilization review to project the impact of cost on patients or the provider?
Reviewed a newly-approved drug to determine whether it’s both financially and clinically reasonable to utilize?
Completed a medication review with a patient?
Guess what…you’ve participated in managed care! These - and everything in between - are managed care experiences.
Once you can recognize it, you will see it in every aspect of your role and will be able to outline those experiences in your resume or interviews. Your experience is valuable to the managed care world if you can only translate it appropriately. If you fully want to embrace managed care pharmacy and experience all that it offers years out of school, it’s also never too late to complete a residency. This is a worthwhile investment and one of the few ways you get to experience such a diverse array of managed care practices in a relatively short time.
The tl;dr of Managed Care Pharmacy
See, unicorns aren’t mythical creatures… they’re bikes wearing costumes! Not to say that managed care is as easy as riding a bike, but it IS reachable! (Image)
Hopefully this post has given you a clearer picture of managed care pharmacy. I also hope that it has made it more accessible and applicable to your current pharmacy practice. It is NOT a mythical, untouchable unicorn, and many of you probably participate in it every day (even if you didn’t recognize it until now)!
Even if managed care is not a path you wish to explore as a career, understanding the roles of your pharmacy colleagues can only make you a better health care provider. Whatever the stage of your pharmacy career, regardless of your past and current experiences, understanding how managed care impacts every aspect of health care (including yours!) will help you to better care for your patients. And if you are interested in managed care pharmacy as a career, check out these additional resources for a jump start: