Managed Care Pharmacy

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