Managed Care Pharmacy Issues

Population health management (PHM) is a key concept in managed care. Improving population health, enhancing the patient experience, and reducing per capita cost are the primary goals of a philosophy called the Triple Aim. PHM extends beyond healthcare organizations, requiring the cooperation of other types of institutions, such as public health departments and social service entities.

The purpose of outcomes research per the Patient Centered Outcomes Research Institute (PCORI) is to assist patients, clinicians, purchasers and policy makers in making informed health decisions by advancing quality and relevance of evidence. The Agency for Healthcare Research and Quality (AHRQ) defines the purpose of outcomes research as a tool to provide evidence about benefits, risks, and results of treatments so clinicians and patients can make more informed decisions.

Health plans, employers and government-sponsored health care programs are focusing their attention on optimizing patient outcomes through the use of medications that have established evidence of efficacy and safety, while providing the highest value.

Disease management is the concept of reducing health care costs and improving quality of life for individuals with chronic conditions by preventing or minimizing the effects of the disease through integrated care. Disease management programs are designed to improve the health of persons with chronic conditions and reduce associated costs from avoidable complications by identifying and treating chronic conditions more quickly and more effectively, thus slowing the progression of those diseases.

Congress passed the Health Insurance Portability and Accountability Act (HIPAA) in 1996. Within that Act are privacy provisions with which covered entities (including all health plans, health care providers and health care clearinghouses [e.g. PBMs] that transmit any health information in electronic form must comply. HIPAA rules provide guidance to covered entities about how to comply with the Act.

The purpose of this paper is to explain how managed care organizations (MCOs) are able to secure lower drug prices from pharmaceutical manufacturers as part of an effort to control drug expenditures.

Press Release: Focusing on what’s best for the patient, leveraging technology to perform real-time benefit checks, and developing trust and transparency among stakeholders are some of the suggestions to emerge from AMCP’s recent Partnership Forum on “Optimizing Prior Authorization for Appropriate Medication Selection.”

Common managed care terms and their meaning.

Learn how managed care pharmacy can play a vital role in patient-centered medical homes.

The concise policy statements included in the AMCP Practice Positions are part of an ongoing process that documents the AMCP's position on professional and practice issues. These practice positions will serve to aid AMCP members in describing their roles and serves as the basis for AMCP’s public policy statements. they also aid in advancing AMCP’s positions to target audiences. These policy statements, approved by AMCP’s Board of Directors, cover a wide range of pharmacy and practice issues and have been derived from existing AMCP Legislative & Regulatory Positions, Medicare Part D Series, Concept Papers, and other policy statements.