What is Managed Care Pharmacy?

“Managed care pharmacy is the practice of developing and applying evidence-based medication use strategies that enhance member and population health outcomes while optimizing healthcare resources”

-The Academy of Managed Care Pharmacy

Goals of Managed Care

  • Prevention of disease
  • Focus on wellness and enhanced quality of life
  • Improved clinical outcomes
  • Quality and accessibility of health care
  • The right therapy at the right time for the right member

Major Tenets of Managed Care

  1. Managed Care is the Thoughtful Allocation of Limited Resources: In healthcare, just like in any other business or project, we only have so many resources (i.e. dollars, clinicians, time) available at our disposal. Managed care is the systematic approach to thinking critically about how can we ensure that we use healthcare dollars and resources in the most optimal and efficient way possible. In managed care, efficiency means improving health outcomes while also considering how much healthcare resources cost.
  2. Managed Care Principles Can Be Found Everywhere: Managed care is most typically associated with health insurance companies and PBMs. This makes sense because health insurance companies pool all the dollars from our premiums, deductibles, and copays and decide what services and drugs should be covered. However, because of the shift to a value-based healthcare system, managed care principles are becoming more prevalent throughout healthcare. Because managed care is such a widely-applied concept in healthcare, it can take many different forms depending on the perspective of the relevant stakeholder (e.g. health plan, Accountable Care Organization, community pharmacy, etc.).
  3. Managed Care is Population Health-Based: While in pharmacy school, we are often focused on the one patient in front of us. Managed care, on the other hand, is responsible for thinking about large populations of patients, and how health plans or health systems can ensure that patients receive the most appropriate medications in a manner that maximizes safety and efficacy and encourages following guideline-directed therapy.
  4. Managed Care Principles are Important to Everyone: When pharmacy students learn that managed care is behind the dreaded prior authorization process, they may associate managed care with a negative connotation. It is important to drive home that taxpayers and employees are the ultimate “payer” in healthcare. Managed care directly acts to make sure that we use our healthcare dollars optimally, which in turn helps to keep premiums as low as possible.