Introduction to Managed Care Organizations

Introduction to Managed Care

• Managed care is a system of clinical, financial, and organizational activities designed to efficiently provide healthcare services.
• It involves various organizations, payment methods, review mechanisms, and collaborations, often misunderstood in its scope.
• All healthcare and medical insurance professionals can be considered as managing care.

Managed Care Organizations (MCOs)

• A generic term for a managed care plan.
• Examples include HMOs (Health Maintenance Organizations), PPOs (Preferred Provider Organizations), and EPOs (Exclusive Provider Organizations).
• Also includes health plans or prescription benefit management companies (PBMs).

Health Maintenance Organizations (HMOs)

• A type of health insurance where members prepay for services, usually encompassing inpatient and outpatient care.
• Benefits include lower out-of-pocket costs and reduced paperwork.

Pharmacy Benefit Management Companies (PBMs)

• Manage pharmaceutical benefits for MCOs, other medical providers, or employers.
• They facilitate numerous activities like benefit plan design, network management, claim processing, and drug utilization review (DUR).

Pharmacists in Managed Care

• Pharmacists in managed care have a different practice role, requiring additional competencies.
• They monitor patient populations, use database reviews, and consider economic and clinical outcomes.
• They provide clinical drug management, quality-oriented services, and drug distribution/dispensing within managed care organizations.

Pharmacist Role in an MCO

• Drug distribution and dispensing
• Patient safety (DUR, Prior Authorization, Monitoring Programs, and Quality Assurance Programs)
• Clinical program development
• Communication with patients, prescribers, and other pharmacists
• Drug benefit design
• Business management
• Cost management

Drug Distribution and Dispensing

• Pharmacies may provide enhanced services to patients.
• Community pharmacies interact with MCO pharmacists for eligibility and claim processing.
• Mail order pharmacies assess prescriptions, eligibility, and appropriateness.

Patient Safety

• Drug Utilization Review (DUR) identifies prescription problems.
• Prior Authorization (PA) encourages appropriate prescribing.
• Monitoring programs and Quality Assurance programs improve patient safety and drug use.

Clinical Program Development

• Using evidence-based data to create disease management programs.
• Evaluating scientific evidence to select suitable medication for patient groups.
• Conducting outcome-based research.

Communication with Patients, Prescribers, and Pharmacists

• Helping prescribers choose suitable medications for patients' needs and insurance coverage.
• Providing medication history to dispensing pharmacists to identify risk factors.

Drug Benefit Design

• Deciding whether to use a formulary (approved list of medications) and how it should be structured.
• Implementing criteria and procedures for DUR.

Business Management

• Negotiating discounts with drug manufacturers.
• Providing customized clinical reports to meet client needs.

Cost Management

• Encouraging cost-effective drug choices by prescribers.
• Identifying prescription compliance and non-compliance patterns.

Research Areas in Social and Administrative Pharmacy

• Pharmacoeconomics: Analysis of drug costs.
• Professional Society Management: Management of professional groups.
• Outcomes Research: Evaluation of public health interventions.

Quality Assurance

• Systematically achieving required quality.

Pharmacoepidemiology

• Study of drug use and effects in large populations.

Quality-of-Life Studies

• Assessing individual's perception of life in various contexts.

Epidemiology

• Studying the distribution and occurrence of diseases.

Patient Attitudes Towards Pharmacy Profession

• Patients express positive attitudes toward pharmacists providing pharmaceutical care services
• Willingness to pay for these services to reduce medication-related problems.

Patients and Medication Adherence

• Medication adherence is an important area for study.
• Poor adherence to long-term therapies impacts public health.

Patient Preferences

• Determining preferences helps pharmacies improve services.
• Patients base their healthcare choices on factors like competence-based attributes.

Technology in Gathering Data

• Difficulty in collecting pharmacist data.
• Using smartphone application for activity tracking among pharmacists.

Research in SAP: Pharmacy Practice

• Challenges in pharmacy practice require research and solutions.
• Pharmacists working with traditional and complementary medicine products.
• Reluctance among pharmacists in conducting research due to time, training, and support limitations.

Explore the fundamentals of managed care, including its organizational structure and payment systems. Understand various types of managed care organizations such as HMOs, PPOs, and PBMs. This quiz is essential for healthcare professionals looking to deepen their knowledge in managed care systems.