Roles of Pharmacists IN MANAGED HEALTH CARE ORGANIZATIONS. Drug Distribution and Dispensing. Patient Safety

Transcription

1 Roles of Pharmacists IN MANAGED HEALTH CARE ORGANIZATIONS Drug Distributio ad Dispesig Patiet Safety Cliical Program Developmet Commuicatio with Patiets, Prescribers ad Pharmacists Drug Beefit Desig Busiess Maagemet Cost Maagemet

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3 Pharmacists i maaged health care orgaizatios, icludig health plas ad pharmacy beefit maagemet (PBM) compaies, are resposible for the delivery of prescriptio drug beefits to over 200 millio Americas. Typically, a maaged care orgaizatio cotracts their services to a pla sposor, such as a private compay or a govermetal orgaizatio. Pharmacists employed withi these maaged care orgaizatios are resposible for a broad ad diversified rage of cliical, quality-orieted drug maagemet services. WHAT DO Maaged Care Pharmacists DO? There are over 18,000 pharmacists workig for health plas ad pharmacy beefit maagemet compaies. It is their resposibility to make sure that the pla they desig provides idividual patiets with appropriate drugs ad drug therapies, coveietly ad costeffectively. It is a complex job, ivolvig the expert skills of cliically traied pharmacists at every step i the patiet-care process. As with pharmacists who practice i other settigs, pharmacists i maaged care eviromets are committed to esurig that medicatios are available ad used appropriately i order to improve patiets health. They do this by performig fuctios withi the followig categories: Drug Distributio ad Dispesig Patiet Safety Cliical Program Developmet Commuicatio with Patiets, Prescribers ad Pharmacists Drug Beefit Desig Busiess Maagemet Cost Maagemet This brief overview of the may roles of pharmacists withi maaged care orgaizatios is meat to impart a very basic uderstadig of the wide rage of activities that maaged care pharmacists udertake every day. For more detailed iformatio, see AMCP s Cocepts i Maaged Care Pharmacy Series o our website at

4 2 ROLES OF PHARMACISTS Drug Distributio Process i the Maaged Care Settig The pharmacist i the maaged care settig maages the drug distributio process through oe of four approaches: care orgaizatios operate their ow pharmacies. These i-house pharmacies ofte provide ehaced pharmaceutical services because they are members of a fully itegrated patiet care system. Maaged care pharmacists esure that the services delivered by i-house pharmacies are of the highest quality. Through commuity pharmacies: Maaged care orgaizatios cotract with broad-based etworks of participatig pharmacies to fill the prescriptios of their members. Maaged care pharmacists maage the pharmacy etwork, perform drug utilizatio reviews, miimize fraud ad abuse ad iitiate quality assurace programs to esure that the orgaizatio s members have local access to high quality, affordable pharmacy services. Through the maaged care orgaizatio s pharmacies: Some maaged Through mail order or olie services: Some maaged care orgaizatios ow or cotract with mail order ad/or olie pharmacies. Maaged care pharmacists maage these services to esure quality. Through collaboratio with physicias ad other health care professioals: Maaged care orgaizatios have access to several databases of iformatio that lead to a coordiated ad safe drug distributio process. Pharmacists withi maaged care orgaizatios review patiets medicatios to help safeguard agaist uiteded side effects i ew ad existig prescriptios. They work with prescribers ad other health care professioals to esure that the medicatios prescribed are: eligible for coverage, of high quality, affordable ad projected to do o harm.

5 ROLES OF PHARMACISTS 3 Patiet Safety Maaged care pharmacists help esure patiet safety by aalyzig prescriptio claims data to idetify problematic prescriptio use patters, iterveig with prescribers ad patiets to help correct such problems ad educatig prescribers about best practices associated with the use of prescriptio medicatios. They desig ad admiister: prescriptio-related problems such as drug/drug iteractios, duplicatio of drugs, kow allergies, uder- or overdosig or iappropriate therapy. Prior Authorizatio (PA or Prior Auth ) programs: A approval process that ecourages proper use of medicatios ad discourages iappropriate prescribig of medicatios. Fraud ad Abuse programs: Programs that review key drug classes, moitorig for patters of iappropriate use. Drug Utilizatio Review (DUR) programs: This process ca idetify potetial Moitorig programs: Some medicatios require lab-based moitorig or geomic testig (i.e. persoalized medicie) for product selectio or dosig Moitorig programs esure that medicatios are prescribed safely ad used appropriately. Programs also ivolve moitorig patiet regimes for drug iteractios ad medicatio adherece. Moitorig programs esure that medicatios are prescribed safely, used appropriately, ad that patiets receive the best possible outcome. Quality Assurace (QA) programs: Stadard of care programs that ehace patiet safety, improve the ways i which patiets use medicaitos ad esure delivery of high quality service.

6 4 ROLES OF PHARMACISTS Cliical Program Developmet I order to ehace patiet care, particularly for patiets with chroic coditios whose quality of life depeds o prescriptio drugs, maaged care pharmacists desig cliical programs that: Evaluate scietific evidece i order to select appropriate medicatios for a patiet populatio. A thorough evaluatio of the scietific ad cliical data regardig ew medicatios must be made by a pael of cliical experts withi maaged care orgaizatios. Called pharmacy ad therapeutic (P&T) committees, these paels geerally iclude pharmacists, physicias ad other medical professioals. of care. Assess the effectiveess of ew treatmets for diseases compared to stadards Use evidece-based cliical ad research data to create disease maagemet ad medicatio therapy maagemet programs that help patiets live more successfully with their medical coditios ad maage their drug therapies. Pharmacists support physicias i the maagemet of chroic ad complex diseases by moitorig regimes, assistig with cost savig strategies, ad couselig patiets to improve adherece ad help miimize wastes ad reduce costs. Icrease uderstadig of the way i which cliical therapies affect quality of life, ad implemet programs that help esure such quality is achieved. depedet o comprehesive drug therapies. Explore ways of maagig patiets with chroic coditios who are Desig ad coduct outcomes-based research i order to help patiets achieve the desired results from their drug therapy, ad ehace their ability to make quality-of-life decisios. Ecourage appropriate prescribig ad proper use of medicatios through utilizatio maagemet (UM) programs such as prior authorizatio (PA or Prior Auth) ad quatity limit (QL) programs. Pharmacists who practice i a maaged care eviromet are committed to esurig that medicatios are used appropriately.

7 ROLES OF PHARMACISTS 5 Commuicatios with Patiets, Prescribers ad Pharmacists Maaged care pharmacists desig ad use commuicatio protocols, such as those used withi a call ceter or medicatio therapy maagemet program, to esure that there is a exchage of ecessary iformatio betwee patiets, their physicias ad their pharmacists. Commuicatios are required to: updates to assist them i their evaluatio of patiets therapies. Provide patiets with iformatio o their idividual prescriptio history through persoalized reports. Help physicias ad other prescribers choose medicatios that will meet patiets eeds ad be eligible for coverage. Notify physicias ad other prescribers of drug safety alerts ad cliical Educate patiets o their disease state ad o the medicatios they are takig or those beig suggested by their physicias. Provide the poit of care pharmacist with a more complete patiet profile ad guidace o coverage issues to aid them i their delivery of patiet care. Help patiets maage their health care ad help physicias address complex medicatio therapy questios.

8 6 ROLES OF PHARMACISTS Pla Beefit Desig Maaged care pharmacists collaborate with other health care professioals to desig effective beefit structures that will service a specific populatio s eeds. The pharmacist uses cliical kowledge ad practical experiece to address such desig matters as: How to structure a formulary (the approved list of medicatios that a pla will cover) to ecourage appropriate ad cost-effective therapy. Must decide whether the formulary should be restricted or ope. The level of patiet cost-sharig for geeric, preferred brad-ame medicatios, ad o-formulary medicatios must also be established. so, how expasive should the etwork of commuity, mail order ad olie pharmacies be to service the populatio properly; what criteria for quality assurace should participatig pharmacies be expected to meet. Whether a participatig pharmacy etwork should be established ad, if What criteria ad procedures for drug utilizatio should be established to help safeguard that (1) patiet safety ad best outcomes are maximized, ad (2) that patiets receive the correct drug at the correct dosage, uderstad why they are beig asked to take the drug ad are compliat i takig the drug. Whether to establish a specific pla desig for specialty medicatios (i.e. high-cost medicatios that may require special hadlig, admiistratio or moitorig ad are used to treat chroic, complex disease states). Pla desigs may iclude limitig distributio, establishig specific patiet cost-shares ad implemetig utilizatio maagemet requiremets.

9 ROLES OF PHARMACISTS 7 Busiess Maagemet Maaged care pharmacists cotract with employer ad health pla cliets, pharmacies ad maufacturers to structure busiess arragemets that: to meet their idividual populatio eeds. Negotiate with maufacturers for discouts o drug prices for cliets i exchage for movig market share whe cliically appropriate. Allow their cliets to customize cliical ad reportig requiremets Assist cliets i assessig the appropriateess of ew medicatios compared to existig therapeutic optios. Establish etworks of pharmacies to provide accessibility for patiet populatios ad assure participatig pharmacy compliace with patiet safety ad quality programs ad audit requiremets. Cost Maagemet Maaged care pharmacists help their cliets (employers, HMOs, trust fuds, Medicaid, etc.) evaluate ad improve their pharmacy beefit by: Ecouragig prescribers to make cost effective drug choices that are cliically appropriate. Itroducig system itervetios that ehace the quality of patiet care ad save costs. Itegratig improvemets so that costs are actually saved, ot merely shifted. Usig data to idetify adherece ad oadherece with prescribig guidelies, ad, by creatig measures for assessig physicia performace, idetifyig prescribig patters ad determiig opportuities for improvemet. Esurig a scietific evaluatio of cost for ew medicatios by applyig pharmacoecoomics.

10 8 ROLES OF PHARMACISTS About AMCP Missio: To empower its members to serve society by usig soud medicatio maagemet priciples ad strategies to improve health care for all. The Academy of Maaged Care Pharmacy (AMCP) is a atioal professioal associatio of pharmacists, health care practitioers ad others who develop ad provide cliical, educatioal ad busiess maagemet services o behalf of more tha 200 millio Americas covered by a maaged pharmacy beefit. AMCP members are committed to a simple goal: providig the best available pharmaceutical care for all patiets. Some of the tasks AMCP s almost 7,000 members perform iclude: Moitorig the safety ad cliical effectiveess of ew medicatios o the market; Alertig patiets to potetially dagerous drug iteractios whe a patiet is takig two or more medicatios prescribed by differet providers; Desigig ad carryig out medicatio therapy maagemet programs to esure patiets are takig medicatios that give them the best beefit to keep them healthy; ad Creatig icetives to cotrol patiets out-of-pocket costs, icludig through lower copaymets o geeric drugs ad certai preferred brads. These practices, ad more, aim to esure that all patiets ca receive the medicatios they eed to improve their health while at the same time keepig health care costs uder cotrol. AMCP serves its members i may ways, icludig through live atioal cofereces, olie learig programs, research i peer-reviewed literature ad advocacy. Each is desiged with the goal of advacig professioal kowledge, improvig the desig ad delivery of pharmacy beefits, ad ultimately, patiet satisfactio ad health outcomes. We ivite you to joi us if you are a practicig pharmacist or someoe who is ivolved i the practice of maaged care pharmacy. Explore our website at www. amcp.org ad lear more about who AMCP is ad what we do.

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12 INFORMATION. WHEN YOU NEED IT. To access AMCP s website ad lear more about who AMCP is ad what we do, sca this code with your smartphoe or visit N Pitt Street Suite 400 Alexadria, VA Tel 703/ Fax 703/ JUN 2013 / 5,000