Independent community pharmacists are an integral part of the healthcare process. As such, they are also an essential part of managed care models of healthcare.
Although the definition of managed care changes depending on who uses it, pharmacists sit at the heart of the main goal of a managed care model of healthcare: To decrease overall healthcare costs by reducing the chance that patients will need acute or palliative care.
Pharmacists can help minimize healthcare costs for patients and the public by helping patients adhere to their medications and effectively manage their various disease states. They do this through services that only pharmacists can provide, such as medication therapy management and adherence programs. Pharmacists must be active in redefining the term managed care—and their role in it—or be relegated to a back seat in the healthcare process.
The definition of managed care
For community pharmacists, managed care is a loaded term. While the idea of managed care inarguably looks good on paper, it has repeatedly failed to meet its own marks in practice.
It’s hard to argue with the idea of organizing the process; of bringing accountability and a case for financial liability to a healthcare delivery system that operates for the majority of people. However, there are several ‘strings attached’ to managed care organizations that don’t fit their proposed model for better healthcare.
These ‘strings’ include inflated administrative costs, self-serving formularies, and most importantly, the increasing affect of pharmacy benefit managers on provider-patient relationships.
Problems with managed care
Concerns about managed care organizations can be seen on all levels and within almost all professions in the realm of healthcare.
For example, the University of Washington School of Medicine’s Ethics in Medicine Topic and Research guide recognizes and teaches that, “managed care is structured around a variety of incentives to encourage the practice of cost-effective medicine, and to minimize variation in clinical practice patterns. Monetary and nonmonetary incentives raise the ethical concern that physicians may compromise patient advocacy in order to achieve cost savings.” In effect, the managed care model may threaten to rush patients through their examinations, which may negate the farther-reaching healthcare goals of fewer treatments and better care.
Pharmacists deal with these concerns frequently, and typically on a more frank basis than their prescribing physician counterparts. Patients don’t blame their doctor when they’re told that their prescriptions either can’t be filled or aren’t covered by their insurance. They blame the pharmacist, even if they’re informed that they need to contact their insurance companies or their employer’s human resources officer about their concerns.
There’s still hope for the idea of managed care and pharmacists’ function in it. As an industry, pharmacy is changing. By adapting to new opportunities and making a group effort toward revitalization, pharmacists can not only help redefine managed care, they can also more clearly define their role as the healthcare providers they trained to be and are—not just people who can “count to 30”, in the words of Express Script CEO, George Paz.
Working together
Retail pharmacists have traditionally provided a multifaceted offering that is unique among healthcare providers. Yet, the fee-for-product (prescription drugs) model is no longer a sustainable way to do business for many pharmacies. Pharmacies have strived to make up for lost profits with items such as durable medical equipment or OTC products, yet they still continue to struggle.
With the import of PBM and federally defined managed care plans and the rise of computerized data and records, reimbursements have been severely reduced. It is imperative for pharmacists, no matter where they practice their profession, to take action to more carefully—and boldly—define their role in the healthcare spectrum or be relegated to flat rate, zero or even negative reimbursements for both the products and services they provide. How can pharmacists take back control of their profession and help redefine managed care?
Pharmacists must first fight professional apathy. Absolutely nothing can be done to expand and advocate the pharmacist’s role in outcome-based, total-patient care if those whom the movement is centered on do not prioritize these changes.
Every pharmacist should be aware of his or her responsibility to ‘give something back’ to the profession and be not only proud but also willing to ‘pay it forward’ for the future of pharmacy.
Attending conferences and legislative or community events is a good way to stay involved and informed on pending changes and new ideas. There are several state and national organizations that support independent pharmacy businesses. Pharmacists should consider their membership in these associations and groups as an opportunity to expand their livelihood both as an individual business and as an industry.
What you can do individually
“I will embrace and advocate changes that improve patient care,” is the sixth tenant in the recently revised AACP Pharmacist’s Oath. Large group efforts aren’t the only way that pharmacists can expand on their roles as healthcare providers.
The effects of Medication Management Therapy (MTM) have been widely espoused by pharmacists. In-store wellness classes and disease education forums have also had a growing affect on the growth of independent pharmacy.
Community efforts such as The Diabetes Ten City Challenge (DTCC) and the Asheville Project in North Carolina are changing the definition of managed care, too. These projects established measurable practices for pharmacists and incentives for patients with varying diabetic disease states to participate. For example, the “average total healthcare costs were reduced annually by $1,079 per patient compared to projected costs if the DTCC had not been implemented.”
The first rollout of the Asheville Project (which initially focused strictly on diabetics) found that “positive results were realized by month six and have remained fairly consistent from that point forward. Positive results were definitely seen by the end of year one with every program.” Emulating a similar project or program within even smaller communities could significantly expand the independent pharmacist’s role in managed care.
Pharmacists must then focus on one group. It is the largest, most important, and the potentially loudest group of people anyone in a healthcare profession will interact with: the patients. The pa
tients can reach out to the payers (their employers and insurance companies).
Explain the importance of staying connected to one’s own community to your patients. Large, corporate-run pharmacies have no ties or obligations to the areas they serve. Business decisions are handed down to them from afar and are not made with the best interests of the community in mind. Remind your patients about the community pharmacy’s standards of genuine concern for their family’s health and well-being, the personalized care and the attentive staff, too.
Community pharmacists are well positioned to redefine the term managed care and to make it a concept that works in both theory and practice with real, outcome-based results. By taking a firm, united stance against major PBM regulations, by creating measurable wellness and prevention services that yield favorable results, and by asking for the voices of patients to chime in for these advocacy movements, there is no reason that pharmacists cannot redefine managed care.
