An Overview and History of Managed Healthcare
This module provides an overview of healthcare costs and quality, as well as the tools, approaches, and financial incentives used in managed care to improve value. The module also gives a brief history of managed care, including relevant federal legislation and describes various types of managed care plans and organizations.
Cost and Resource Utilization Analyses
This module discusses how healthcare organizations are using cost and resource utilization analyses to improve efficiency.
Cost-Containment Strategies in Managed Healthcare
This module describes cost-containment strategies developed by managed care organizations (MCOs) to reduce the unnecessary use of healthcare resources and associated costs.
Crisis in US Healthcare Costs -Access and Quality
This module discusses three significant healthcare challenges: cost, quality, and access.
Criteria for Product Approval to the Formulary
This module focuses on the formulary approval process in both managed care organizations and hospitals, and how decisions are made regarding which drugs are approved for formulary inclusion.
Current Issues in Managing Healthcare
This module explores issues facing healthcare stakeholders as they make decisions related to managing and improving healthcare.
Current Trends in Healthcare
This module discusses some of the solutions and approaches being used by healthcare providers, payers, and consumers to control costs and improve patient care.
Disease Management as a Component of Managed Care
This module discusses the key elements of disease management systems and explores how disease management programs are evaluated.
Evaluating and Improving the Quality of Managed Care
This module highlights some of the key organizations and approaches being used to evaluate and improve the quality of care in MCOs, including:
• The Institute for Healthcare Improvement’s Triple Aim
• Federal quality-related initiatives
• Accrediting organizations, including The National Committee for Quality Assurance (NCQA) and the Joint Commission
• Performance measurement and transparency
• Clinical guidelines
Follow the Dollar–from Manufacturer to Patient
This module presents a high-level view of the distribution and payment of pharmaceutical products. It traces products through the supply chain and examines the role of various stakeholders, including suppliers (pharmaceutical companies, wholesalers, and pharmacies), payers (government and health plans), and consumers (patients). Along the way, you will gain an appreciation for the complex relationship between drug spending and those who pay the bills.
This module describes three major formulary design concepts: open, closed, and incented or multi-tier, and discusses the emerging approach to formulary structure, and value-based formulary design.
Hospital and Managed Care Formularies
This module discusses the use of formularies in hospital and managed care/organized customer settings.
Hospitals and Post-Acute Providers in the Managed Care Environment
This module discusses the changing role of acute care hospitals and the growing role of post-acute providers, especially home care, hospice, and skilled nursing facilities.
How Trends and Forces in Managed Care are Impacting the Pharmaceutical Industry
This module discusses four major managed care trends that are influencing the pharmaceutical industry:
1. A growing focus on outcomes research and management fueled, in part, by concerns over costs/value.
2. Increased use of clinical practice guidelines, disease management programs, evidence-based medicine, and personalized medicine.
3. New contractual relationships.
4. New business-oriented decision makers and a consumer-focused market.
Identifying Partnering Opportunities
This module explores various opportunities for partnerships that can result in a competitive edge while helping physicians meet current challenges.
Impact of Value-Based Healthcare on the Sales Environment
This module reviews the implications of managed care for sales professionals. It looks specifically at how value-based approaches to healthcare is impacting the sales process and the sales professionals' role.
Information Technology in Managed Healthcare
This module describes the various functions and capabilities of health IT while highlighting some of the remaining challenges and obstacles.
Major Healthcare Payers and Managed Care Payment
This module provides an overview of the major payers and payment arrangements. As payers continue to try and contain healthcare costs, they are shifting from traditional indemnity or fee-for-service payment arrangements with providers to various risk-based arrangements, including capitation, bundled payment, and shared savings. Many of these arrangements—which are sometimes called value-based payment—also incentivize providers to improve clinical quality and the patient experience.
Managed Care An Evolving Approach
This module explores the evolution of managed care from an approach that restricted choices and options, mainly as a way to control costs, to a broader performance improvement methodology that focuses on managing the quality, experience, and cost of care provided to a defined population of patients or members.
Managed Care and the Expanding Care Team
This module looks at the trends in managed care that affect and influence physicians, as well as the evolving and expanding care team, which includes nurse practitioners, physician assistants, pharmacists, and case managers.
This Micro Minute describes the various forms of Managed Care Organizations through the years and how, though a variety of cost cutting strategies, this provider type has offered an alternative to fee-for-service care.
Opportunities for Representatives in Managed Healthcare
This module describes the emergence of managed care divisions in many pharmaceutical companies and the implications it has for field sales. The module also discusses several aspects of a representatives’ job that are critical to success in today’s marketplace.
Strategies for Managing the Pharmacy Benefit
This module describes the key methods used by health plans, insurers, and hospitals to manage the pharmacy benefit. These methods include: cost sharing through tiered formularies and higher copays, influencing prescribers' medication choices, implementing formulary control measures such as prior authorization and generic and therapeutic substitution, conducting periodic drug utilization evaluation (DUE) for specific products or entire classes, and implementing clinical practice guidelines, step therapy, and disease management programs to optimize pharmacological therapy. The module concludes by considering the possible effects on an insurer or MCO of managing a pharmacy benefit and formulary too restrictively.
Streamlining Healthcare through Integration Alliances and Outsourcing
This module discusses three strategies (integrated delivery systems, alliances, and outsourcing) that are borrowed from business management to streamline healthcare delivery.
Streamlining Healthcare through Reengineering and Consolidation
This module reviews two streamlining strategies (reengineering and consolidation) that are borrowed from business management.
The Evolving Structure of Life Science Sales
This module looks at how horizontal management and its emphasis on teamwork, as well as the changing landscape of decision makers, are influencing life science sales.
The Managed Care Pharmacy
This module discusses current strategies for managing pharmacy coverage, the changing role of the pharmacist, and the role of pharmacy benefit management (PBM) companies.
The Pharmacy and Therapeutics Committee
This module focuses on the role of the P&T Committee in the formulary system. It describes the structure and functions of the P&T Committee and explains the actual drug approval process and the restrictions and limitations that might be imposed on a drug once it is approved. In addition, this module describes the criteria that are used to determine whether a drug is accepted for the formulary or rejected.
This module discusses the rationale behind formularies and considers the advantages and disadvantages that come with their use.
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