Managed Care Pharmacy Practice

by Navarro, Robert P.

Edition: 2nd

ISBN13: 9780763732400

ISBN10: 0763732400

Format: Hardcover

Pub. Date: 2008-12-25

Publisher(s): Jones & Bartlett Learning

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Summary

Managed Care Pharmacy Practice, Second Edition offers information critical To The development and operation of a managed care pharmacy program. The text also covers the changes that have taken place within the delivery of pharmacy services, now that a higher percent of the population is enrolled in some type of "managed" health care organization. The Second Edition reflects contemporary health care management and policy issues, details how the value of pharmaceuticals is assessed by health plans and PBMs, and discusses how value-based formularies are developed and managed. Health care policy issues are addressed from a societal perspective to illustrate how managed care organizations respond to, or lead, public policy decisions. The Second Edition has been thoroughly updated to reflect the significant changes in development and execution of managed care pharmacy benefit management. The Second Edition includes a glossary, As well as new chapters and extended topics in: Drug Dossier Development and Applications Self-funded pharmacy benefit management Contracting with pharmaceutical manufacturers the impact of HIPAA on pharmacy benefit management Healthcare Benefits from the Employer Plan Sponsor Perspective Value of Pharmaceuticals Medicare Part D Public Policy and Managed Care Pharmacy AMCP Format for Formulary Submission Pharmaceutical contracting with MCOs and PBMs Medical Therapy Management Programs (MTMPs) Pharmacy & Therapeutics Committees in Managed Care Operations Drug Formularies the role of employer groups in pharmacy benefit development and management "Specialty pharmacy:" the new pharmacy benefit management developed to cover injection-based biologicals created by pharmaceutical manufacturers the complex pharmacy benefit design options available today Implementing MTMPs as a basis for developing the next generation of clinical pharmacy programs to support disease management View Chapters One and Two!

Contributors	p. xvii
Foreword	p. xxi
Preface	p. xxiii
Acknowledgments	p. xxv
Fundamentals of Managed Care Pharmacy Benefit Management	p. 1
The U.S. Health Care System and the Development of Managed Care	p. 3
Introduction to U.S. Health Insurance Industry	p. 4
Evolution of the Health Insurance Industry	p. 6
Economic Basis for the Development of Managed Care	p. 7
Early Development of Managed Care	p. 8
HMO Act of 1973	p. 11
Federal and State Growth in Managed Care: Medicare and Medicaid	p. 13
MCOs: More than HMOs	p. 14
Physician Reimbursement Mechanisms	p. 19
Gatekeeper Physicians	p. 22
Risk Sharing of Pharmacy Cost	p. 22
Carve-Out and Ancillary Health Care Benefits	p. 22
Quest for Quality	p. 23
Impact of Managed Care on Physicians and Pharmacists	p. 24
Member Involvement in Managed Care	p. 26
Conclusion	p. 27
Pharmacy Benefit Management Principles and Practices	p. 29
Basis for Pharmacy Benefit Management	p. 29
Principles of Pharmacy Benefit Management	p. 32
Growth of PBMs	p. 33
Pharmacy Benefit Management Program Components	p. 36
Advanced Pharmacy Benefit Management Components	p. 43
Measuring Pharmacy Benefit Management Program Performance	p. 43
Conclusion	p. 45
Pharmacy Benefit Design, Contracting, and Marketing	p. 47
Business Basis for Pharmacy Benefit Management	p. 47
Corporate and Government Impetus for Pharmacy Benefit Management	p. 49
Legal Basis of Pharmacy Benefit Management	p. 50
Benefit Design, State Requirements	p. 52
Principles of Marketing Pharmacy Benefits	p. 53
Payer and Patient Expectations and Decision Points	p. 55
Role of Members in Pharmacy Benefit Provider Selection	p. 57
Pharmacy Performance Measurements Important in Marketing	p. 59
Marketing Campaign Advertisement Examples	p. 60
Marketing Process	p. 60
Pharmacy Benefit Contracting Components	p. 62
Pharmacy Benefit Management Contracting Trends	p. 64
Risk Contracting	p. 65
Overview of Impact of Medicare and Medicaid	p. 65
Risk-Contracting Elements and Executions	p. 68
Payer Expectations	p. 70
Performance Measurement	p. 72
Future Trends in Pharmacy Benefit Design and Contracting	p. 73
Conclusion	p. 76
Appendix 3-A	p. 77
Appendix 3-B	p. 83
Pharmacy Distribution Systems and Network Management	p. 89
Pharmacy Program Distribution Options	p. 90
Community Pharmacy Provider Networks	p. 90
Pharmacy Provider Network Development	p. 92
Pharmacy Provider Network Contracting	p. 93
Participating Pharmacy Provider Agreement	p. 94
Participating Pharmacy Provider Manual	p. 95
Participating Pharmacy Network Management Issues	p. 95
Measuring Performance	p. 97
Audits	p. 98
Reports	p. 100
Member Satisfaction	p. 100
In-House Pharmacies	p. 101
Mail Service Pharmacy	p. 107
Developing an Integrated Distribution System	p. 108
Pharmacist's Role	p. 111
Impact of Managed Care on the Profession of Pharmacy	p. 114
Conclusion	p. 114
Appendix 4-A	p. 116
Pharmacy Data and Information Systems	p. 125
Scope of Pharmacy Information Management	p. 125
Pharmacy Information Management Systems	p. 127
PMSs and Electronic Data Interchange	p. 134
Role of Switching Companies	p. 135
Internet Technology	p. 137
Adjudication Systems	p. 138
Other MCO Information Systems	p. 141
Conclusion	p. 143
Drug Formulary Management	p. 145
History and Purpose of Drug Formularies	p. 145
Definitions	p. 147
Why Formularies?	p. 148
Decision-Making Process	p. 151
Formulary Exception Process	p. 157
Formularies' Relationship to Other Pharmaceutical Care Practices	p. 158
Future Directions	p. 161
Conclusion	p. 163
Drug Utilization Review Strategies	p. 167
History and Current Role of DUE/DUR	p. 167
Types of DURs	p. 170
Steps in Conducting DURs	p. 173
Application of DUR in Pharmacy Benefit Management	p. 175
Prior Authorization	p. 176
Prospective DUR	p. 178
Physician Education Programs	p. 179
Performance Measurement of DUR Programs	p. 180
Evolution of DUR	p. 181
Conclusion	p. 182
Member Satisfaction Strategies	p. 185
Importance of Member Satisfaction	p. 186
National Committee for Quality Assurance and Health Plan Employer Data and Information Set	p. 189
Satisfaction Measurement among Employer Groups	p. 191
Member Satisfaction with Pharmacy Benefits	p. 192
Conclusion	p. 197
Pharmacy Program Performance Measurement	p. 199
Role of Pharmacy Benefits in Overall Health Plan Performance	p. 199
Pharmacy Performance Metrics	p. 200
Measuring Performance of Various Components	p. 207
Interpreting Results of Pharmacy Measurement	p. 208
Interpreting Cost Metrics	p. 208
Communication of Pharmacy Program Results	p. 210
Application of Results for Program Improvement	p. 212
Advanced Outcomes Management Metrics	p. 216
Linking Pharmacy Programs to Overall Medical and Economic Outcomes	p. 219
Conclusion	p. 220
Pharmacy Benefit Management Companies	p. 221
Genesis of PBMs	p. 221
Growth and Evolution of PBMs	p. 226
Outsourcing Pharmacy Benefit Management to a PBM	p. 230
Financial Arrangement between PBMs and Their Customers	p. 236
Projecting Cost Savings Using PBM Services	p. 237
Reintegrating the Value of PBM Services	p. 238
Contracting for PBM Services	p. 239
Conclusion	p. 240
Advanced Pharmacy Benefit Management Strategies	p. 243
Medicaid Pharmacy Benefit Management	p. 245
Legislative History	p. 245
Administration of Medicaid Benefits	p. 247
Funding Medicaid Benefits	p. 248
Medicaid Eligibility	p. 248
Medicaid Services	p. 249
Medicaid Benefit Design	p. 250
Managed Care Waivers	p. 250
Medicaid Managed Care Contracts	p. 251
Performance Measures and Member Satisfaction	p. 252
Medicaid Pharmacy Benefit Design	p. 252
OTC Product Coverage	p. 253
Medicaid Prescription Copayments	p. 253
Dispensing Fees	p. 254
Pharmaceutical Manufacturer Rebates	p. 255
Challenges and Opportunities in Medicaid Pharmacy Benefit Management	p. 255
Medicaid Demographic Challenges	p. 255
Developmental and Cultural Issues	p. 256
Traditional Fee-For-Service Medicaid Benefit Management Challenges	p. 257
Managed Care Challenges in Providing Medicaid Benefits	p. 259
Pharmacy Benefit Management Opportunities	p. 261
Future Managed Care Medicaid Trends	p. 264
Conclusion	p. 267
Medicare Pharmacy Benefit Management	p. 269
The Social Security Act of 1965 and the Tax Equity and Fiscal Responsibility Act	p. 269
Benefits Covered under Medicare	p. 272
Types of Medicare Programs	p. 272
Why Medicare Enrollees Prefer HMOs to Traditional Medicare	p. 274
Prescription Use and the Medicare Patient	p. 275
Management of the Medicare Prescription Drug Benefit	p. 276
Location of Network Pharmacies	p. 277
Drug Formularies	p. 277
Mail Order	p. 280
Drug Utilization Review	p. 280
The Future of Medicare	p. 281
Conclusion	p. 281
Quality Improvement Initiatives in Managed Care	p. 285
Defining Quality Health Care	p. 285
Assigning Accountability	p. 289
Measuring Quality	p. 290
Current Quality Improvement Initiatives	p. 293
NCQA	p. 294
Joint Commission	p. 297
American Accreditation Healthcare Commission/The Utilization Review Accreditation Commission	p. 302
FACCT	p. 303
AHCPR	p. 304
HCFA	p. 306
Other Quality Improvement Initiatives	p. 306
Future of Quality Measurement in Managed Care	p. 307
Role of Pharmacists	p. 309
Conclusion	p. 311
Health Informatics Systems	p. 313
Evolution of Pharmacy Data Standardization	p. 314
EDI and Electronic Commerce	p. 315
Data and Information Needs of Managed Care	p. 318
Pharmacy and Medical Claims Integration	p. 324
Electronic Medical Record Data	p. 328
Building a Data Warehouse	p. 332
Patient Outcomes Assessment	p. 336
Electronic Prescribing	p. 337
Merging Retrospective and Transactional Data	p. 340
Pharmacy and Health Telematics	p. 341
On-Line Patient Marketing	p. 342
Conclusion	p. 343
Provider and Vendor Risk Contracts	p. 347
Pharmacy Risk Contracting	p. 347
Physician Risk Contracts	p. 352
Reimbursement Agreements	p. 359
Choosing a Reimbursement Methodology	p. 364
Quality Issues	p. 365
Forecast	p. 366
Conclusion	p. 368
Disease Management Programs	p. 371
Definition and Goals	p. 372
Rationale	p. 374
Medical Conditions Appropriate for Disease Management	p. 375
Disease Management Process	p. 376
Growth of Disease Management	p. 378
Role of Pharmacy Benefit Management Companies	p. 378
Pharmaceutical Manufacturer Role in Disease Management	p. 379
Role of Physicians in Disease Management	p. 380
Role of Pharmacists in Disease Management	p. 382
Role and Source of Disease Management Guidelines	p. 386
Role of Drug Formularies in Disease Management	p. 388
Modifying Participant Behavior	p. 388
Barriers to Successful Programs	p. 391
Specialty Carve-Out and Carve-In Disease Management Companies	p. 391
Measuring Program Performance	p. 392
Conclusion	p. 392
Pharmacoeconomic Research and Applications in Managed Care	p. 397
Basics of Pharmacoeconomic Research	p. 400
Application of Pharmacoeconomics in Pharmaceutical Companies	p. 402
Use of Pharmacoeconomic Data for Effectiveness Claims	p. 404
Role of Pharmacoeconomic Research in Product Management	p. 408
Pharmacoeconomic Information Strategies within Pharmaceutical Companies	p. 410
Packaging Pharmacoeconomic Data for Use by P and T Committees	p. 413
Role of Pharmacoeconomic Data in Evidence-Based Drug Formularies	p. 416
Research Opportunities for Managed Care Organizations and PBMs	p. 418
Role of Pharmacoeconomics in Decompartmentalizing Plan Management	p. 418
Sources of Data	p. 423
Opportunities for Pharmacists in Pharmacoeconomic Research and Applications	p. 428
Conclusion	p. 429
The Role of the Pharmaceutical Industry in Managed Health Care	p. 433
Influence of Managed Care on the Sales of Pharmaceuticals	p. 434
Relationship of Pharmaceutical Manufacturers to Managed Care	p. 435
Evolution of the Pharmaceutical Marketplace	p. 435
Managed Care Marketing Strategy Development	p. 442
Contractual Relationships between the Pharmaceutical and Managed Care Industries	p. 443
Pharmaceutical Company Support Services for Managed Care	p. 445
Future Relationship of Pharmaceutical Manufacturers with Managed Care	p. 447
Pharmacy Practice Issues in Managed Care	p. 449
The Impact of Managed Care on Pharmacy Practice	p. 451
Impact of Managed Care Programs on Pharmacy	p. 452
Reimbursement for Managed Care Prescriptions	p. 454
Administration of Managed Care Prescription Contracts	p. 458
Managed Care Strategies for Pharmacists	p. 466
Effect of Managed Care on Hospital Pharmacies	p. 470
Conclusion	p. 471
Pharmaceutical Care in Managed Care	p. 475
Current Trends	p. 476
Examples of Pharmaceutical Care in Managed Care	p. 480
Impact of Pharmaceutical Care in Managed Care: Cost and Quality	p. 488
Reimbursement for Pharmaceutical Care: Cognitive Services	p. 490
Conclusion	p. 493
Pharmacist Career Path Opportunities in Managed Care	p. 497
The Future of Pharmacy under Managed Care	p. 497
Preparing for a Career in Managed Health Care	p. 499
Novel Career Opportunities	p. 501
Maintaining Career Viability	p. 501
Questions Surrounding an Uncertain Future	p. 502
Professional Responsibilities toward Career	p. 504
Conclusion	p. 504
Ethical Aspects of Pharmacy Practice in Managed Care	p. 507
Examples of Ethical Issues and Concerns	p. 508
Ethical Values: Their Place in Pharmacy Practice	p. 511
Ethical Principles and Concepts in Pharmacy Practice	p. 516
Resources for Managing Ethical Concerns in Pharmacy Practice	p. 520
Conclusion	p. 523
Drug Policy and Regulation in Managed Care	p. 525
Food and Drug Administration Issues	p. 525
Direct-to-Consumer Advertising	p. 531
Patient "Bill of Rights" Initiatives	p. 532
Patient Privacy Issues	p. 536
Fraud and Abuse and Consumer Protection Legislation	p. 541
Therapeutic Interchange	p. 543
Narrow Therapeutic Index Drugs	p. 545
Employee Retirement Income Security Act	p. 547
Licensing	p. 550
Any Willing Provider and Freedom of Choice Legislation	p. 551
Mail Service Pharmacies	p. 553
Conclusion	p. 554
International Opportunities for Pharmacists in Managed Care	p. 557
Managed Care Techniques	p. 560
Austria	p. 562
Denmark	p. 562
Finland	p. 562
France	p. 563
Germany	p. 563
Italy	p. 563
The Netherlands	p. 563
Norway	p. 564
Sweden	p. 564
Switzerland	p. 564
United Kingdom	p. 565
Career Opportunities Abroad	p. 565
Conclusion	p. 567
Future of Pharmacy Benefit Management	p. 571
Forces of Change	p. 572
Reaction and Interaction of Change Forces	p. 574
Impact of Forces of Change	p. 575
Pharmacy Practice in the Year 2000 and Beyond	p. 589
Conclusion	p. 590
Glossary	p. 593
About the Contributors	p. 625
Index	p. 632
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