A Peek Into Managed Care Pharmacy and the Role of a Managed Care Pharmacy Resident
The world of pharmacy offers so many opportunities and avenues for pharmacists. As the profession evolves, it’s important to know what options are available. One of them is managed care pharmacy, a growing field and a viable option for those with a PharmD.
Managed care pharmacists design and implement best practices to offer quality patient care that is cost-effective to patients, payers, employers, and government.
In pharmacy school, where the focus is mostly to prepare students to think clinically, managed care is often elective or voluntary through professional organizations. In an effort to share more career paths for pharmacists, Nabila Ismail, PharmD, interviewed Sarah Pawlak, a PGY-1 managed care resident, to learn about her journey into managed care.
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Nabila Ismail: How did you hear about managed care?
Sarah Pawlak: I first heard of managed care in my first year of pharmacy school. I don’t remember the exact details, but I know it was just one lecture on the very basics of managed care. Honestly, at that point, I did not understand the opportunities pharmacists have in this space. I joined our AMCP chapter as a student, which helped me understand more of the inner workings of managed care and the different roles a pharmacist can have at a health plan or PBM.
How I truly learned more about this area was from my two closest friends in pharmacy school. They worked for a local health plan, and they felt I would enjoy the work. I was able to attend a P&T meeting at their workplace during my P2 year and that really solidified my interest.
Then I sought out two APPE rotations at a health plan and PBM, which allowed me to become more well rounded in managed care. I thought a residency in managed care would be the best way for me to have a comprehensive understanding of all of the different departments and roles a pharmacist can have in this space, so that’s what I pursued.
What drew you to managed care and what do you like most about it?
I was drawn to the fact that you can help patients on two separate levels, through direct patient care and population health. The goal of managed care is to provide patients with the most effective and safe medications while controlling costs. I feel that it is so important, especially for our more vulnerable populations, such as patients on Medicaid. I am passionate about increasing patients’ access to medication and helping them live a healthy and safe life.
What does a day as a managed care pharmacy resident look like?
The life of a managed care pharmacist really depends on the department you work in. I am currently a resident, so I go on 6-week rotations in each department at the health plan. Generally speaking, though, I work Monday through Friday. I spend my time attending meetings, working on projects, and completing the daily tasks based on the department. Below are some examples of specific daily duties based on the department I worked in:
MTM clinical pharmacist: I make telephone outreach calls to Medicare members to complete medication reviews, and then make recommendations to both the patient and their provider to optimize their medication regimen and address any problems the patient may have.
Formulary clinical pharmacist: I prepare monographs, review prior authorization criteria, create new indication reports and medication safety reports, and conduct annual drug class reviews for our bimonthly P&T meetings. This can also include presentations for the meeting.
Prior authorization review clinical pharmacist: I review prior authorization requests from provider offices and use evidence-based medicine to make a decision on approval or denial. This can include reaching out to provider offices for more information if the chart notes provided are not sufficient. I’m also involved in triaging and answering customer service requests that need a pharmacist’s clinical opinion.
Specialty clinical pharmacist: I review and evaluate contracts for drug pricing and reimbursement, evaluate specialty medication for potential cost savings, dose optimization opportunity, and utilization of appropriate site of care per policy.
Clinical quality pharmacist: I created educational documents for providers to help improve Healthcare Effectiveness Data and Information Set (HEDIS) and Stars measures, completed and presented a drug utilization review for multiple sclerosis, created a pathway to treat for opioids, and engaged in developing a plan to improve member experience measures.
What sources and resources helped you pursue this path as a student?
I feel that stepping outside of my comfort zone from community pharmacy (where I worked as a student), and seeking opportunities in managed care before choosing my APPE rotations was very important for me to recognize all that managed care has to offer. My rotations in managed care really opened my eyes to the work done to help patients receive the most effective and safe medication, while controlling costs.
Also I feel that attending AMCP Nexus and ASHP Midyear allowed me to connect with residency programs I was interested in, and ultimately helped me match. Unfortunately, managed care is not a major focus in pharmacy school, but there are opportunities through AMCP, APPE rotations, and internships that can help students determine if managed care is a good fit.
Now that you’re in residency and have more exposure, what opportunities exist in managed care for pharmacists?
Pharmacists have many opportunities in managed care. You can be a managed care pharmacist that is involved in direct patient care, such as a medication therapy management pharmacist, or you can be a formulary pharmacist that creates policies for population health. I feel that you are really able to use your clinical knowledge and be involved in important initiatives to help patients have access to affordable, safe, and effective medication.
How can pharmacists use their experience and knowledge in this field?
I find that managed care is actually very clinical, more than you’d expect. Whether it’s working directly with patients, policy-making, or data analytics, you have the opportunity to help patients on a larger scale using evidence-based medicine and research. You use your knowledge from pharmacy school and grow beyond that as well. There is opportunity to grow and expand your skill sets in areas like business management and pharmacy administration, which are an added bonus and not touched upon heavily in school either. I find that it is a challenging yet rewarding field for a pharmacist.
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