8/6/2019 Managed Care 11

1/19

MANAGED PATIENT CARE

8/6/2019 Managed Care 11

2/19

MANAGED CARE

y An organized health care delivery system

designed to improve both the quality and

the accessibility of health care, including

pharmaceutical care, while containing costs.

8/6/2019 Managed Care 11

3/19

8/6/2019 Managed Care 11

4/19

WHAT IS A MANAGED CARE PHARMACIST?

y The areas of opportunities for pharmacists to coordinate patientcare include but are not limited to data integration,communication management with physicians and patients,

outcomes research efforts, drug utilization review, diseasemanagement, academic detailing, cost analysis programs, andpharmacy benefit design.

y In addition, pharmacists are able to qualify and quantifythe results of different therapies and programs, and

therefore add value to the health care team.

8/6/2019 Managed Care 11

5/19

NEED OF MANAGED CARE IN HEALTH

CARE SYSTEM

y To provide comprehensive pharmaceutical care and to work

directly with other health care providers to determine the

most effective pharmaceutical treatment for patients.

8/6/2019 Managed Care 11

6/19

ASSUMPTIONSWITHMANAGED CARE

y If you keep people healthy, you reduce costs.

y If you only give people what they need (as opposed to what

they want), you can reduce costs.

yIf you make providers and patients aware of costs, they will

be more prudent in their use of services.

8/6/2019 Managed Care 11

7/19

HOW DO MANAGED CARE PLANS AFFECT QUALITY

OF CARE?

y Studies have shown that elderly, poor and chronically ill

patients have worse physical outcomes under Managed

care.

y Hospitals under managed care plans more frequentlydeny admission or prematurely discharge mentally ill

patients.

8/6/2019 Managed Care 11

8/19

POTENTIAL BENEFITS PATIENTS

y Less over-treatment

y More preventive care

y Lower cost

y Minimal paperwork

y Low or no co-payment and deductibles

8/6/2019 Managed Care 11

9/19

POTENTIAL BENEFITS PHYSICIANS

y Lower practice start-up costs

y Dependable income

y Regular hours

y Structured practice

y Incentives for cost-effective care

y Assured patients

8/6/2019 Managed Care 11

10/19

POTENTIAL BURDENS PATIENTS

y Incomprehensible benefit plans

y Limits on specialty services, hospitalization, etc.

y Physician is no longer the patients advocate

8/6/2019 Managed Care 11

11/19

POTENTIAL BURDENS PAYERS

y Complex health care plans

y Inadequate data concerning outcomes, quality of care

y Concerns about price-fixing, monopolization

y Uncertainty concerning liability

8/6/2019 Managed Care 11

12/19

Choice

Cost Quality

Conflicts

8/6/2019 Managed Care 11

13/19

8/6/2019 Managed Care 11

14/19

.

y .

TYPES OF HEALTH ECONOMICS EVALUATION

Types of healtheconomic evluation

CBACost benefit

analysis

CEACost effective

analysis

CUACost utility analysis

8/6/2019 Managed Care 11

15/19

DUR

y Process used to assess the appropriateness of drug therapy

by engaging in the evaluation of data on drug use in a given

health care environment against predetermined criteria and

standards

8/6/2019 Managed Care 11

16/19

DUR INCLUDES.

y ABC / VENANALYSIS

y High cost, high volume, clinically important drugs are identified by ABC / VENanalysis.

y ABCANALYSIS

y ABC analysis is the method by which drugs are divided according to their

annual usage (unit cost times annual consumption)y ClassA items 1020% of the items that account for 7580% of the funds

spent

y Class B items 1020% of items and 1520% of expenditures

y Class C items 6080% of items and 510% of expenditures

y ABC analysis can be used to give priority to class A items in making drug

selection and procurement decisions as well as for inclusion in DUR.

8/6/2019 Managed Care 11

17/19

VEN ANALYSIS

y VENANALYSIS

y Setting priorities for drug selection, purchasing and reviewing in which drugsare classified according to their health impact

y V = vital drugs

y E = essential drugs

y N = non-essential drugsy Vital drugs = that are potentially life-saving (e.g. vaccines) that have

significant withdrawal side-effects such that a regular supply is necessary (e.g.propranolol, insulin, steroids)

y Essential drugs = that are effective against less severe, but significant formsof illness

y Non-essential= for minor or self-limiting illnesses, drugs that are ofquestionable efficacy, and drugs that have a high cost for marginal therapeuticadvantage.

8/6/2019 Managed Care 11

18/19

PHYSICIANS REACT TO MANAGED CARE

y The general reaction of physicians to managed care is negative:

y Quality care is being denied.

y Managed care is profit-driven.

y Managed care will bring on a single payer national plan.

y Physicians get hassled and burdened with paperwork.

y Traditional physician-patient relationship is poisoned.

y Physicians income is reduced.

y Managed care induces physicians to be manipulators.

8/6/2019 Managed Care 11

19/19

CONCLUSION