The ABC's of Managed Care - D, E, and F

Hello again everyone! Now that monsoon season is almost over in Ann Arbor, I'm ready to take off my poncho (just kidding, I don't actually wear a poncho) and start writing again. Last time we kicked it old school with A, B, and C of our tour through managed care. Bet you can guess what's coming next..

D: Dynamic - Managed care is a dynamic environment. Why you ask? Let's just take a quick look at a couple of snippets from the FDA's Press Announcements just this month:

• May 23, 2011 - FDA approves Incivek for hepatitis C
• May 20, 2011 - FDA approves Sutent for rare type of pancreatic cancer
• May 20, 2011 - FDA approves new HIV treatment
• May 13, 2011 - FDA approves Victrelis for Hepatitis C
• May 06, 2011 - FDA approves new treatment for rare type of pancreatic cancer (This is not the same drug as on May 20th!)
• May 02, 2011 - FDA approves new treatment for Type 2 diabetes

This doesn't even take into consideration the surprising number of new drug formulations that are constantly being approved. Each of these newly approved drugs and formulations has to be reviewed carefully and decisions must be made as to their place in therapy. Clearly, managed care organizations like Blue Care Network (BCN) have their hands full adapting to the ever-changing world of pharmacy.

E: Evidence-based medicine - One of the exciting things about managed care is that you are making decisions not just for one individual patient, but for an entire population of patients. This is where evidence-based medicine (EBM) comes into play. With so much on the line, clinical pharmacists at BCN have to delve deep into the literature to find the best evidence to support their clinical decisions. Some of the questions the clinical pharmacists have charged me with investigating have been pretty tough so far:

• What is the correct dose and interval for IVIG in the treatment of relapsing-remitting multiple sclerosis (RRMS) exacerbations?
• Should alemtuzumab (Campath) be used in MS? Or should the patient try fingolimod (Gilenya) first? Or natalizumab (Tysabri)?
• What evidence is there for IVIG in urticarial vasculitis? (We could only find less than 10 case studies in the literature of this!)

I never thought I would say this, but that EBM class we all dreaded P1 year is truly paying off. Thank you Dean Welage; we will miss you greatly!

F: Fun - You can't have a career in pharmacy without a little phun! I can honestly say that I've had a fantastic time so far at my internship at BCN. The atmosphere there is truly unique. The dress is casual. The coffee is flowing. And each computer is equipped with an instant messenging feature to allow quick, fun communication between co-workers. It's a pretty tight-knit group at BCN, and the fun atmosphere seems to cultivate a culture of hard-work, efficiency, and teamwork. In the words of arguably the most entertaining boss in the world, Michael Scott: "What is the single most important thing for a company? Is it the building? Is it the stock? Is it the turnover? It's the people. The people." Well said, Mr. Scott. It is the people at BCN who make it such a great place to work.

Well, that's it for this week's adventures in managed care.

Your homework for next week: be dynamic, have fun, and uh... don't forget your EBM.

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