Managed Care Pharmacy Practice

ISBN-10: 0763732400
ISBN-13: 9780763732400
Edition: 2nd 2009 (Revised)
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Description: Managed Care Pharmacy Practice explains the fundamentals of developing and operating a successful managed care pharmacy benefit, and also supplies insightful guidance on professional careers in the field.

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Book details

List price: $93.95
Edition: 2nd
Copyright year: 2009
Publisher: Jones & Bartlett Learning, LLC
Publication date: 12/11/2008
Binding: Hardcover
Pages: 633
Size: 7.00" wide x 9.00" long x 1.25" tall
Weight: 2.486
Language: English

Managed Care Pharmacy Practice explains the fundamentals of developing and operating a successful managed care pharmacy benefit, and also supplies insightful guidance on professional careers in the field.

Contributors
Foreword
Preface
Acknowledgments
Fundamentals of Managed Care Pharmacy Benefit Management
The U.S. Health Care System and the Development of Managed Care
Introduction to U.S. Health Insurance Industry
Evolution of the Health Insurance Industry
Economic Basis for the Development of Managed Care
Early Development of Managed Care
HMO Act of 1973
Federal and State Growth in Managed Care: Medicare and Medicaid
MCOs: More than HMOs
Physician Reimbursement Mechanisms
Gatekeeper Physicians
Risk Sharing of Pharmacy Cost
Carve-Out and Ancillary Health Care Benefits
Quest for Quality
Impact of Managed Care on Physicians and Pharmacists
Member Involvement in Managed Care
Conclusion
Pharmacy Benefit Management Principles and Practices
Basis for Pharmacy Benefit Management
Principles of Pharmacy Benefit Management
Growth of PBMs
Pharmacy Benefit Management Program Components
Advanced Pharmacy Benefit Management Components
Measuring Pharmacy Benefit Management Program Performance
Conclusion
Pharmacy Benefit Design, Contracting, and Marketing
Business Basis for Pharmacy Benefit Management
Corporate and Government Impetus for Pharmacy Benefit Management
Legal Basis of Pharmacy Benefit Management
Benefit Design, State Requirements
Principles of Marketing Pharmacy Benefits
Payer and Patient Expectations and Decision Points
Role of Members in Pharmacy Benefit Provider Selection
Pharmacy Performance Measurements Important in Marketing
Marketing Campaign Advertisement Examples
Marketing Process
Pharmacy Benefit Contracting Components
Pharmacy Benefit Management Contracting Trends
Risk Contracting
Overview of Impact of Medicare and Medicaid
Risk-Contracting Elements and Executions
Payer Expectations
Performance Measurement
Future Trends in Pharmacy Benefit Design and Contracting
Conclusion
Appendix 3-A
Appendix 3-B
Pharmacy Distribution Systems and Network Management
Pharmacy Program Distribution Options
Community Pharmacy Provider Networks
Pharmacy Provider Network Development
Pharmacy Provider Network Contracting
Participating Pharmacy Provider Agreement
Participating Pharmacy Provider Manual
Participating Pharmacy Network Management Issues
Measuring Performance
Audits
Reports
Member Satisfaction
In-House Pharmacies
Mail Service Pharmacy
Developing an Integrated Distribution System
Pharmacist's Role
Impact of Managed Care on the Profession of Pharmacy
Conclusion
Appendix 4-A
Pharmacy Data and Information Systems
Scope of Pharmacy Information Management
Pharmacy Information Management Systems
PMSs and Electronic Data Interchange
Role of Switching Companies
Internet Technology
Adjudication Systems
Other MCO Information Systems
Conclusion
Drug Formulary Management
History and Purpose of Drug Formularies
Definitions
Why Formularies?
Decision-Making Process
Formulary Exception Process
Formularies' Relationship to Other Pharmaceutical Care Practices
Future Directions
Conclusion
Drug Utilization Review Strategies
History and Current Role of DUE/DUR
Types of DURs
Steps in Conducting DURs
Application of DUR in Pharmacy Benefit Management
Prior Authorization
Prospective DUR
Physician Education Programs
Performance Measurement of DUR Programs
Evolution of DUR
Conclusion
Member Satisfaction Strategies
Importance of Member Satisfaction
National Committee for Quality Assurance and Health Plan Employer Data and Information Set
Satisfaction Measurement among Employer Groups
Member Satisfaction with Pharmacy Benefits
Conclusion
Pharmacy Program Performance Measurement
Role of Pharmacy Benefits in Overall Health Plan Performance
Pharmacy Performance Metrics
Measuring Performance of Various Components
Interpreting Results of Pharmacy Measurement
Interpreting Cost Metrics
Communication of Pharmacy Program Results
Application of Results for Program Improvement
Advanced Outcomes Management Metrics
Linking Pharmacy Programs to Overall Medical and Economic Outcomes
Conclusion
Pharmacy Benefit Management Companies
Genesis of PBMs
Growth and Evolution of PBMs
Outsourcing Pharmacy Benefit Management to a PBM
Financial Arrangement between PBMs and Their Customers
Projecting Cost Savings Using PBM Services
Reintegrating the Value of PBM Services
Contracting for PBM Services
Conclusion
Advanced Pharmacy Benefit Management Strategies
Medicaid Pharmacy Benefit Management
Legislative History
Administration of Medicaid Benefits
Funding Medicaid Benefits
Medicaid Eligibility
Medicaid Services
Medicaid Benefit Design
Managed Care Waivers
Medicaid Managed Care Contracts
Performance Measures and Member Satisfaction
Medicaid Pharmacy Benefit Design
OTC Product Coverage
Medicaid Prescription Copayments
Dispensing Fees
Pharmaceutical Manufacturer Rebates
Challenges and Opportunities in Medicaid Pharmacy Benefit Management
Medicaid Demographic Challenges
Developmental and Cultural Issues
Traditional Fee-For-Service Medicaid Benefit Management Challenges
Managed Care Challenges in Providing Medicaid Benefits
Pharmacy Benefit Management Opportunities
Future Managed Care Medicaid Trends
Conclusion
Medicare Pharmacy Benefit Management
The Social Security Act of 1965 and the Tax Equity and Fiscal Responsibility Act
Benefits Covered under Medicare
Types of Medicare Programs
Why Medicare Enrollees Prefer HMOs to Traditional Medicare
Prescription Use and the Medicare Patient
Management of the Medicare Prescription Drug Benefit
Location of Network Pharmacies
Drug Formularies
Mail Order
Drug Utilization Review
The Future of Medicare
Conclusion
Quality Improvement Initiatives in Managed Care
Defining Quality Health Care
Assigning Accountability
Measuring Quality
Current Quality Improvement Initiatives
NCQA
Joint Commission
American Accreditation Healthcare Commission/The Utilization Review Accreditation Commission
FACCT
AHCPR
HCFA
Other Quality Improvement Initiatives
Future of Quality Measurement in Managed Care
Role of Pharmacists
Conclusion
Health Informatics Systems
Evolution of Pharmacy Data Standardization
EDI and Electronic Commerce
Data and Information Needs of Managed Care
Pharmacy and Medical Claims Integration
Electronic Medical Record Data
Building a Data Warehouse
Patient Outcomes Assessment
Electronic Prescribing
Merging Retrospective and Transactional Data
Pharmacy and Health Telematics
On-Line Patient Marketing
Conclusion
Provider and Vendor Risk Contracts
Pharmacy Risk Contracting
Physician Risk Contracts
Reimbursement Agreements
Choosing a Reimbursement Methodology
Quality Issues
Forecast
Conclusion
Disease Management Programs
Definition and Goals
Rationale
Medical Conditions Appropriate for Disease Management
Disease Management Process
Growth of Disease Management
Role of Pharmacy Benefit Management Companies
Pharmaceutical Manufacturer Role in Disease Management
Role of Physicians in Disease Management
Role of Pharmacists in Disease Management
Role and Source of Disease Management Guidelines
Role of Drug Formularies in Disease Management
Modifying Participant Behavior
Barriers to Successful Programs
Specialty Carve-Out and Carve-In Disease Management Companies
Measuring Program Performance
Conclusion
Pharmacoeconomic Research and Applications in Managed Care
Basics of Pharmacoeconomic Research
Application of Pharmacoeconomics in Pharmaceutical Companies
Use of Pharmacoeconomic Data for Effectiveness Claims
Role of Pharmacoeconomic Research in Product Management
Pharmacoeconomic Information Strategies within Pharmaceutical Companies
Packaging Pharmacoeconomic Data for Use by P and T Committees
Role of Pharmacoeconomic Data in Evidence-Based Drug Formularies
Research Opportunities for Managed Care Organizations and PBMs
Role of Pharmacoeconomics in Decompartmentalizing Plan Management
Sources of Data
Opportunities for Pharmacists in Pharmacoeconomic Research and Applications
Conclusion
The Role of the Pharmaceutical Industry in Managed Health Care
Influence of Managed Care on the Sales of Pharmaceuticals
Relationship of Pharmaceutical Manufacturers to Managed Care
Evolution of the Pharmaceutical Marketplace
Managed Care Marketing Strategy Development
Contractual Relationships between the Pharmaceutical and Managed Care Industries
Pharmaceutical Company Support Services for Managed Care
Future Relationship of Pharmaceutical Manufacturers with Managed Care
Pharmacy Practice Issues in Managed Care
The Impact of Managed Care on Pharmacy Practice
Impact of Managed Care Programs on Pharmacy
Reimbursement for Managed Care Prescriptions
Administration of Managed Care Prescription Contracts
Managed Care Strategies for Pharmacists
Effect of Managed Care on Hospital Pharmacies
Conclusion
Pharmaceutical Care in Managed Care
Current Trends
Examples of Pharmaceutical Care in Managed Care
Impact of Pharmaceutical Care in Managed Care: Cost and Quality
Reimbursement for Pharmaceutical Care: Cognitive Services
Conclusion
Pharmacist Career Path Opportunities in Managed Care
The Future of Pharmacy under Managed Care
Preparing for a Career in Managed Health Care
Novel Career Opportunities
Maintaining Career Viability
Questions Surrounding an Uncertain Future
Professional Responsibilities toward Career
Conclusion
Ethical Aspects of Pharmacy Practice in Managed Care
Examples of Ethical Issues and Concerns
Ethical Values: Their Place in Pharmacy Practice
Ethical Principles and Concepts in Pharmacy Practice
Resources for Managing Ethical Concerns in Pharmacy Practice
Conclusion
Drug Policy and Regulation in Managed Care
Food and Drug Administration Issues
Direct-to-Consumer Advertising
Patient "Bill of Rights" Initiatives
Patient Privacy Issues
Fraud and Abuse and Consumer Protection Legislation
Therapeutic Interchange
Narrow Therapeutic Index Drugs
Employee Retirement Income Security Act
Licensing
Any Willing Provider and Freedom of Choice Legislation
Mail Service Pharmacies
Conclusion
International Opportunities for Pharmacists in Managed Care
Managed Care Techniques
Austria
Denmark
Finland
France
Germany
Italy
The Netherlands
Norway
Sweden
Switzerland
United Kingdom
Career Opportunities Abroad
Conclusion
Future of Pharmacy Benefit Management
Forces of Change
Reaction and Interaction of Change Forces
Impact of Forces of Change
Pharmacy Practice in the Year 2000 and Beyond
Conclusion
Glossary
About the Contributors
Index

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