Trends in Managed Care Pharmacy: Preparing for the Future

he mandate of managed care organizations (MCOs) is to provide quality health care while responsibly managing health care costs. Managed care has brought significant change to the way health care services are provided, most notably by integrating many care components and linking them financially and clinically. It has also produced changes in how health care providers and patients participate in the system and relate to each other. As managed care has grown in the past decade, employers, health care providers, and patients have demanded more autonomy, choice, and flexibility. Along with choice, however, comes the potential for increasing costs and a need to determine the bearer of those costs. External factors such as new technology, procedures, and drugs, combined with changing member demographics and increasing numbers of Medicare and Medicaid patients, have also had an impact on costs. These trends suggest the need for a reassessment of the direction managed care organizations must take to both succeed in business and focus on patient needs. One method for improving both patient care and the financial outlook of MCOs involves making better use of the vast amounts of clinical and financial data available within managed care systems, especially in the pharmacy area. Addressing the demands of consumers, physicians, and employers requires an accurate assessment of costs and clinical outcomes. Many organizations are not yet using an integrated approach that includes several, if not most, components of care. Pharmacy departments are in a unique position to view cost and clinical outcomes across the continuum of care, from primary care visits to hospital inpatient care and post-hospitalization, because they touch the patient at each stage of care. Pharmacy departments can take the initiative in developing models for improved patient and financial outcomes by using the information available for the benefit of the entire organization. This may mean going directly to the information-systems department, identifying subsets of patients who use significant resources, and examining ways to improve resource use to optimize outcomes. It may mean conducting studies of particular patient populations. Regardless of the tactics used, pharmacy can often be the focal point to highlight important clinical and economic issues and the results of interventions. This article reflects on several key managed care evolutionary trends and some challenges for the future. Managed care data cited were supplied by SMG Marketing Group, Inc., and published in the Aventis Managed Care Digest Series, a central source of information about all aspects of managed care.1 In addition, this paper includes examples demonstrating how pharmacists can use information available to them within their own organizations to highlight areas for improvement in patient intervention while also decreasing costs for the entire health plan.