The ABC's of Managed Care

Hello everyone! My name is Bernie Marini, and I am an incoming P4 who will be doing an internship in managed care this summer at Blue Care Network (BCN). Yesterday was actually my first day, and it was definitely a change of pace from working retail. Managed care is a new world for me, and every day I am surprised by how attractive a career in Managed care might be. Since I (and you, maybe) are new to managed care, we'll start with the ABC's. Prepare to be Kindergartner-ized (I'm an author of a blog now, so I can make up words):

A: Acronyms - Managed care is FULL of acronyms. It's like learning a new language. At first, during meetings, I was pretty lost - terms like ERISA, ECRI, HEDIS, MAC, CFI, PREFALT, PCOT, AGL, FAIR, FACETS, and NCQA just flew over my head. It's made for a difficult start, but I'm starting to get the hang of it. I now know that PREFALT letters are those that are sent to providers when a PA is denied, letting them know what the preferred alternatives are. If I'm feeling ambitious, I might make a glossary for future interns by the end of the year.

B: Boring? Not so much. Every day is completely different. There are a lot of meetings in managed care, but they vary greatly from day to day. Today I attended my first webinar on a successful safety initiative in the Philadelphia area known as the Partnership for Patient Care. I had another meeting about compounding fraud, and another one discussing branching logic built for certain medication prior authorizations (more on this later...). I also am being assigned a different project just about every single day. I'm currently working on several short informational stories and brochures regarding COPD guidelines for both providers and patients, to improve compliance with NCQA guidelines. Next I'll be working on a presentation for the members of the Chrysler Automotive group on their medication use within the health plan compared to all other BCN members.

C: Clinical - One cool part about this internship is that I have my very own cubicle, and I get to work right next to the clinical pharmacists there....wait... whaaaat? Clinical Pharmacists? In managed care? That's right, BCN employs many clinical pharmacists, and much of the work done at BCN is very clinically based. The pharmacists have to create the branching logic for prior authorizations and other formulary rules regarding medication selection by members of the HMO. For example, let's take the hypothetical example where a doctor writes a prescription for tizanidine (Zanaflex), a muscle relaxant. Because of safety concerns with tizanidine, this would require a prior authorization, and the form that the doctors fill out asking questions such as "has the patient tried cyclobenzaprine (Flexeril)? (Y/N)..." is created by clinical pharmacists. The answers to these questions determine whether or not the prior authorization is approved. These safety and efficacy decisions concerning formulary rules and prior authorizations are one of the the many responsibilities of clinical pharmacists at BCN.

I think that's enough ABC's for today. Stay tuned for more adventures in managed care!

Next week: D, E, and F - get excited.

-Bernie