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OBJECTIVES

    Objectives: Upon completion of the chapter and exercises, the student pharmacist will be able to
  1. Identify the goals and types of managed care organizations.

  2. Illustrate managed care business management techniques.

  3. Explain formulary management, drug utilization review, and disease state management.

  4. Discuss outcomes research.

  5. Identify current directions in managed care.

Patient Encounter

Discussion (based on the Patient Encounter from Chap. 2, pages 18-19):

A 26-year-old African American Gold Medal Olympic bicyclist was struck by a car, flung 30 feet into the air, and fell into an embankment. He was training for his second Olympic trial and was well known in the community as being devoted to his sport. He was unconscious at the scene. After stabilization in the hospital, it was determined that his spinal cord was completely severed below T10. He sustained a serious head injury, but it was anticipated that he would probably be able to talk and communicate his wishes over time. However, a long rehabilitation period was anticipated for the head injury with uncertain degree of return to full preaccident mental abilities, and the paraplegia was permanent. During his recovery period, he needed surrogates (proxies) to make his decisions for him because of his temporary lack of decision-making capacity. The patient had several medical complications including pneumonia and urosepsis. After several weeks, several family members, including his wife, who was the main surrogate decision maker, voiced their concern that the patient, given his athletic prowess, would “never want to be a cripple” and suggested that, because of the patient's poor quality of life, antibiotics be withheld and the patient be allowed to “die with dignity.” Both the patient and his wife were avid athletes, and the subject of paraplegia had never been discussed. Because of his love of the sport and their life style of athleticism, she was sure he would not want to be a “cripple.” You, as the pharmacist, are approached by the family to cease administration of antibiotics.

The goals of the managed care organizations are as follows:

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Prevent disease.
Focus attention on wellness.
Improve medication therapy.
Base decisions on the entire population versus the individual.
Cost containment.
Are there programs a managed care organization could promote to prevent bicycle accidents for the members they serve?
What would the programs entail and how would they be implemented?
Would a program to prevent bicycle accidents fit into a larger accident prevention program?
What would an accident prevention program include?

INTRODUCTION

Managed care organizations (MCOs) can trace their beginnings back to prepaid health plans in the early 1900s. These early group prepaid practices were the model and precursors for our current health maintenance organizations (HMOs). The HMO Act of 1973 authorized federal funds to help develop HMOs and preempted state laws that prohibited prepaid plans. At the close of 1996, there were over 600 HMOs in the ...

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