Managed Care Pharmacy: Principles and Practice

Position your company to keep pace in the changing environment of Managed Care!Managed Care Pharmacy: Principles and Practice analyzes trends in pharmacy benefit systems to provide physicians, pharmacists, payers, benefit consultants, and pharmaceutical companies with ways to preserve quality pharmaceutical care while reducing costs. Each chapter, written by an expert in the field, offers proven suggestions that will help you choose or develop a pharmacy benefit system that will maximize the goals of managed care organizations, pharmacists, and consumers. Discussing the importance of evaluating the success and cost-effectiveness of pharmacy benefit policies, this book gives you examples for creating and organizing monthly reports that will reveal how money is being spent or saved and if consumers are satisfied.Managed Care Pharmacy uses data and strategies that will help you understand and implement pharmacy benefits, enabling you to: examine past health care strategies--both successful and unsuccessful--to understand present changes increase pharmacist involvement in health plans by offering capital contracts as rewards evaluate models of money flow for pharmacy reimbursements choose between staff-model pharmacies, community (retail) pharmacies, and types of pharmacy networks to cut costs and increase customer satisfaction use the financial status of the benefit program, clinical outcomes reporting, prescription claims, and forms of electronic data interchange (EDI) to evaluate the cost-effectiveness and quality of care of various pharmacy systemsCombining present knowledge and future implications, this book gives you insight and information into several different aspects of pharmacy benefits. This allows you to understand how important your role is in this area of health care. Complete with a glossary of managed care terms and formats for sample monthly reports and plan enrollment forms, Managed Care Pharmacy will help you work towards providing better, less costly pharmacy benefits for consumers and health care professionals.

Table of Contents:
Contents About the Editors Contributors Foreword Preface Chapter 1. Evolution of the Contemporary Health Care Delivery System Overview The Evolution The Supremacy of FFS Medicine Creation of Protective Barriers Managed Care Fundamentals The Move Toward Reform Individual Practice Associations (IPAs) and Network Development The Transition to Reform The Rise of Reform The Demand for Reform Continues Conclusion Chapter 2. Contemporary Managed Care Organizations (MCOs) and Their Structure What Are MCOs? The Great Depression Changes Medicine Too Birth of the Third-Party Administrator What Do Dams Have to Do with Doctors The Postwar Years Health Care Cost?s New Trajectory The Next Generation of MCOs Chapter 3. Pharmacy in Managed Health Care Pharmacy Distribution Systems Mail Service Formulary Management Expanded Role of the Pharmacy Department The Future Conclusion Chapter 4. Pharmacy Reimbursement in Managed Care Funds Flow Models Paying Pharmacies From the Pharmacy?s Point of View Conclusion Chapter 5. Defining and Shaping Financing Needs Putting the Pharmacy Benefit Management (PBM) Phenomenon in Perspective How Employers Came to Focus on Dug Price and Not on Pharmaceutical-Associated Costs What Employers Really Wanted All Along Getting What Employers and Other Financiers Want--The Vendor Selection Process What Employers Want from PBMCs What Employers Want from Drug Manufacturers What Employers and Other Financiers Want in the Future Chapter 6. Pharmacy Distribution Systems Introduction Staff-Model Pharmacies Physician Dispensing Mail-Service Pharmacy Community (Retail) Pharmacy Integrated Pharmacy Networks Summary Chapter 7. Evolving Role of Systems in Pharmacy Benefit Management (PBM) Early Attempts at Automation Opportunities for Technology Leverage Other “Strategic” Automation Improvements Other Relevant Health Care Systems Innovations A Glimpse into the Near Future Chapter 8. The Drug Formulary, Product Selection, and the Pharmacy and Therapeutics (P&T) Committee Formulary Pharmacy and Therapeutics (P&T) Committee Product Substitution Chapter 9. DUR and DUE in Managed Competition The DUR Process DUE versus DUR Evolution of DUR/DUE The Future Disease Management Conclusion Chapter 10. Data Capture and Information Reporting Systems Introduction Uses of Reported Information Types and Sources of Information Information Reporting Information Delivery Systems The Future Chapter 11. Quality Assurance and Outcomes Research Introduction Approaches to Quality Assessment Continuous Improvement in Health Care Outcomes Management (OM) Conclusion Chapter 12. Management of Drug Therapy in Health Programs The Problem The Solution What to Do Next Chapter 13. Pharmacoeconomics (PE): Applications for Managed Care Perspectives on Health and Managed Care Quantitative Tools Pharmacoeconomics and Outcomes Management (OM) General Steps in an Economic Study Multiple Paths Toward Cost-Effective Pharmacy Services Challenges and Opportunities Chapter 14. Off-Label Use and Experimental Treatment Background and Significance of the Use of Approved Drugs for Off-Label Indications The Role of the FDA in the Approval Process and in Ensuring Safety and Efficacy How Other Countries Regulate Prescribing for Off-Label Indications Duel Nature and Ethical Dilemma of Using Approved Drugs Off Label Setting Standards of Medical Practice Impact of Off-Label Use on Managed Care Chapter 15. Rx-to-OTC Conversion: Managed Care Implications Perspectives on Self-Care OTC Medication--Consumer Issues The Rx-to-OTC Shift Potential Risks and Benefits of the Switch Managed Care and OTC Medications Conclusion Chapter 16. Worldwide Review of Pharmacy Benefit Controls Introduction History of Drug Benefit Design International Controls on Manufacturer Price Negotiations Controls on Prescribers? Cost of Prescribing Review and Comparison Controls at the Pharmacy Controls on Consumers Other Techniques Future Directions Chapter 17. Future Trends in Managed Care Pharmacy Networks Performance Standards Risk Sharing Electronic Superhighway Chapter 18. Marketing and Selling to Managed Care: Pharmaceutical Industry Perspective The End of an Era A New Perspective on the Market Marketing Strategies with a Managed Care Focus A Gaze into the Future Conclusion Chapter 19. Drug Benefit Design Introduction Goals of the Managed Drug Benefit Design Basic Components of a Managed Pharmaceutical Benefit Member Cost Sharing Current Issues and Trends Conclusion Chapter 20. Measuring the Performance of Managed Pharmacy Benefit Programs Introduction Identify the Target Outcomes Financial Experience Clinical Outcomes Economic and Humanistic Outcomes Conclusion Appendix Eligibility Setup and Section Criteria Eligibility/Enrollment Information Rx Program Plan Benefit Checklist Benefits Checklist Client Accounting Information Reports Distribution Administrative Services Agreement Services Agreement Services and Fees for Prescription Drug Program Outpatient Prescription Medication Endorsement and Addendum Pharmacy Program Management Information Reports Sample Reports Glossary of Managed Care Terms Index Reference Notes Included