Pharmacy Managed Care Services: The Proactive management of costs, unavailability, and turnover

speaker, author, and recognized by the Global Gurus as the most influential thought leader in health and well-being. So what I usually do is I love to speak from the stage, but unfortunately we don't have that convenience or luxury as much as we want to. So we're actually here on the webinar, but it shouldn't be any different. So what I'd like to ask everybody is to get involved. Give me a shout out. Where are you from? Your name? What pharmacy? Are you a student? Are you a community Do you work in hospital? Are you a clinical pharmacist? Yeah, so someone already knows the drill here. So it's, is it Iman? Yeah. Hi, Iman. How are you? Good afternoon to you. So yeah, anybody who's on here, please get on the call and let us know your name, where you're calling from. And of course, Mohammed, I think. Sharfateen, how are you? Mustafa, Jalal. Yep, Muhammad is hospital pharmacist. How are you? Mustafa is on the webinar, is that what that is? All right, Sarah. Sarah is from where? Sarah from Turkey? No, from Libya, but she lives in Turkey. Okay, Iman is from Lebanon. Hi, shout out, big shout out to Lebanon. Let's see, who's this? This is Munir, I think. Is it Mohib? See the problem? Oh, Mohib. OK, thank you so much. A clinical toxicologist from Iraq. Welcome, welcome, welcome. Thank you so much for sharing and joining in. Sattar, hi. Good evening. OK, where are you from? Where are you calling from? It's evening time by you, I guess. Community pharmacy. Ali is community pharmacist. OK, wonderful. Where are you from, Ali? Ali Murad from Alexandria, Egypt. Yay. All right, send a good shout out. I'm also from Egypt. So where's my Egyptian posse on here? Where's the Yemen and everybody from the Arab world? Kurdistan is from— Mustafa's from Kurdistan. Fifth year. Oh, you're a student. Very nice. Very nice. So Tare is a PhD pharmacology toxicology in Iraq. Wonderful. Wonderful. Thank you so much for sharing. And yeah, this is what I want. Keep up the energy. Let's have it more interactive and get on the chat. And whoever else is on here, We'll give you another minute to post on here. Let us know who you are, where you're calling from, what year of pharmacy, what kind of pharmacy, sorry, community pharmacy, clinical pharmacist. Yeah, who else is on here? All right, so wonderful. Okay, 28 people. I'm supposed to get 28 messages. All right, Nancy, student, lives in Almen but is Egyptian. Okay, all right, Nancy, how are you? Thank you for joining us today. All right, so if anybody— nobody wants me to give you a shout out, we'll get started with our webinar. Nancy, okay. Khalid from Egypt. Hey Khalid, how are you? Thank you, thank you so much for joining us today. Murad from Algeria, community pharmacist. All right Murad, thank you so much for posting and getting interactive with us today. All right, so yes, uh, hey everyone. Okay, so thank you so much for joining and I welcome everybody that's on the webinar today. So let's get started. Okay, so let me see if technology works in our favor today and I'm able to find— yes, it's working. Wonderful. All right, awesome. So what's today's topic? So today we're going to talk about pharmacy managed care services, and it is a service and you should consider incorporating this very important service, especially post epidemic, during epidemic, or wherever this is going to lead us, whether you think we're going to get back to normal or this is the new normal, right? So there's a lot of people who are just waiting for everything just to get back to the way it was, and people are just pivoting and being more flexible to having this being the new normal. And this is no different, right? We're in healthcare. There are things we need to now be flexible and continue serving our patients in the best way possible, protecting ourselves in the meantime. And of course, pharmacy managed care services is actually one of the leading services that we need to consider, understand. Now, I know a lot of, um, there's some students on here today and there's, uh, some, um, people from the, some pharmacists from the community pharmacy background, and I know a lot of people will say, well, I'm not working in a hospital to worry about pharmacy managed care services, or I don't work with patients, you know, directly in that clinical setting, or I'm not a clinical pharmacist, but I feel that managed care services is actually across the board. I think you should understand and incorporate it whether you're in community, clinical, or hospital setting. And it's, again, it's what we call what the evolved consumer or involved patient or client, whatever you want to call your consumer at the end of the day, is what they're looking for, right? They're looking for that understanding, the managed care, whether it's a clinical managed care on their overall health and well-being or the actual medication management as well. So we're going to get into all that understanding of the different managed care services that will allow you to be more proactive in the management of not only the cost, but the unavailability of certain drugs, especially with COVID And if flights are being delayed, as well as the people are not going— able to go back home or not going to visit their GP doctor back home or whatever it may be, right? So, um, that has to all be taken into consideration, understanding when we're talking and understanding managed care services. And of course, to reduce the turnover, because at the end of the day, if you're not well equipped or not understanding of these key tools, there is a huge turnover, um, for, um, more, uh, clinical understanding, quote unquote, healthcare professionals and you need to be on the cutting edge and sharpening those leadership and healthcare pharmacy or managed care pharmacy skills as well. Okay, so is there any— can everybody hear me before we get started? Oh, Vangara, Dr. Vangara. I think, I hope I'm always giving him a shout out or her at every webinar. I'm hoping I'm spelling it or pronouncing it right. Yeah, good evening to you, sir or madam. Vangara, yes. Yes. Okay. And Nancy. Yes. Thank you, Nancy, for your message. All right. So actually today there are a couple of important pharmacy management skills that we need to understand in order to sharpen that service managed care services in healthcare, which starts, I believe, with the human approach. At the end of the day, what we're doing for our patients is we're making it a managed care or patient-centric approach. So whether we're talking from the nutrition side or exercise or any of those, of course, step therapy tools, we'll, we'll get into all that in a minute, or we're actually talking about the actual medications, the DUR, drug utilization review, and all those other important skills that we need to understand when we're talking about managed care pharmacy. Okay, so managed care pharmacies actually uses a number of best practices. We're going to go to the 4 main ones that I call 4 Ms that offer quality care and also cost-effective coverage for patients, payers, employers, and government all at once. And we will be actually discussing, like I mentioned before, I'm so— how to improve pharmacy managed care for patients, reduce costs. Because unfortunately, because of the epidemic, many people have lost their jobs, or even before losing their jobs, even there was always this high cost that the patient had to actually pay out of pocket in order to meet the minimum payment, if you will, and then their services or their coverage will kick in after that. So of course, we want to make sure not only do we give the quality, but we also want to consider the cost for the end user or for our patient because compliance is key, right? All that we're doing for the patient and making it patient-centric is again towards compliance, the improvement of the health and wellbeing of our patient or client. All right, so what is managed care exactly? So let me open the chat here and let me, give me someone, I wanna know the understanding that you guys have. I'm sure any clinical pharmacist who's on here or a hospital setting pharmacist would understand what exactly managed care is, as well as even 5th-year students would understand, because at the end of the day, it is the clinical services that we offer to our patients and our clients. Okay, um, I think he's saying he can hear me. Thank you, thank you for— yeah, that would be really bad if I go on all this time giving you all this valuable information, no one can hear it. Yeah, So please let me know, anybody on here who's a clinical pharmacist or working in hospital setting, and just give me what you guys do perhaps that might be considered under the umbrella of managed care services. Gosh, you guys were, you knew your names right away. You were very active in the beginning. I was like, oh my God, everybody's awake. Everybody's really interacting, giving me your name and where you're from and the pharmacy, and then now silence. Like, I could hear crickets out there. Come on, guys. Anybody? Just any, like, word or what your understanding of what is managed care. Okay, so hope to know Dr. Hanan Selim. Okay, thanks, Mustafa. All right, so I'll ask you later. Maybe you guys could take some tea and caffeine by the time we get to the middle of the webinar, see who's awake at that point. Okay, so all right, so what is managed care? So let's break it down for you guys. Okay, so let's say, uh, I'll explain what managed care on from the healthcare, uh, chunked up, if you will, umbrella general term, right? So managed care in healthcare uses a number of, again, best practices that offers quality care and cost-effective as well, um, for coverage for patients, for payers, employers, Okay, so on an umbrella, managed care is just— it's a holistic opportunity to not only give quality care to the patient or the end user, but as well as considering bringing down the cost. Because at the end of the day, that's why hospital pharmacies, for example, we'll also discuss this in a minute, is we have something called formularies, right? And this is all part of contracting with third parties or manufacturers to have the best deals, if you will, that will give the, again, the quality medication but at a lower cost for the inpatients, for example, in the hospital. Okay, so now a managed care pharmacy is the practice of developing and applying evidence-based medication that uses strategies to enhance the member of the population's health outcome while optimizing the healthcare resources. And again, like I said, this includes not only private sectors, but again, public sectors or government sectors, because at the end of the day, they all want to optimize and be able to offer their services to as many people in the population, with of course being able to do that and reduce the cost while doing it. Okay, so again, the skill sets for an improved pharmacy managed care program, not only is for the evolved environment that we now live in called the post-epidemic or the epidemic crisis in health and well-being. But also what has developed from this evolved environment is of course what we call now the evolved consumer. And what do I mean by the evolved consumer? So the evolved consumer is now not only who used to come into your pharmacy, take the medication once a day, twice a day, you explain to them take it before food or after food. Warfarin, for example, you should take it alone or measuring your lab works and just all that additional information that we already give the patient as a pharmacist or a healthcare professional, right? But now the evolved consumer is not only wanting to know those basics, but they want to know what they should eat, what they should avoid eating, what exactly— if you tell them 3 times a day, okay, what exactly time of the day should they, you know, be taking taking the medication. So they're all about getting the information from the resources from you as the healthcare professional and the most accessible, I must say, healthcare professional that they have, because otherwise they would have to make an appointment, see the doctor, or even not having that access to the nurse. And of course, the pharmacist is always there, the most accessible healthcare professional. So the demand is on us more to give that more information or the extra service if you will, to this evolved consumer. And of course, managed care is actually one of the important services that we offer to the evolved consumer that we're talking about. So managed care pharmacists per se, they help employers, they help public payers, insurers, individuals access safe, effective medications while managing costs. And we'll talk about how the managed care pharmacists exactly do that. And actually, there's a trend in the U.S. Of actually managed care as an option to not only give the best quality medication to the end user but also reduce the cost. And that's actually very important part of the service that a managed care pharmacist offers because everyone, whether private or public, like I said, sectors, they're always looking to reduce costs because at the end of the day, if they reduce the cost, they're able to help more people our members in during any of these situations that we're living in, like the epidemic and crisis. Okay. So ensuring access to service, because growing particularly in the publicly financed programs, so I'm actually, I grew up in the US. And for example, let's say Medicaid. So a lot of people who got off or made redundant from work, they go straight to Medicaid as a financed program that helps them with this crisis that everybody's going through with the leaving their— or losing their jobs. And of course, assisted healthcare is part of that finance program. So the largest government healthcare initiatives indicated the use of managed care services for individuals who are duly eligible for public assistance and could result in cost savings for the government. So if anything, managed care services are looked at more aggressively now than ever because of the situation that we're living in with the epidemic. So with the benefits of some of the clinical and administrative tools used by managed care pharmacy is to achieve the goals of ensuring, again, safe and effective. It's not, again, not only about giving the cost-effective medication, but of course, it's all as well balancing it and making sure it's safe and effective medication again reducing the cost, and that's going to be actually our focus and primary understanding when we talk about managed care pharmacists. So there's— so the Mukaddas is saying, I was a pre-medical student but now I'm doing business marketing. Okay, so Anna Marie from Lebanon. All right, so we've got a few people here, so I wanted to also give them a shout out. All right, so let's get right into it here. What are the 4 most important, what I call the 4 N's, if you will, of the pharmacy managed care? Any guesses while I take a sip of water here? Mustafa? Anna? See, now when I— Murad. So now when I call you guys out, your names, next time you guys come on the webinar, I'm not putting— you'll be like, I'm not going to put my name or she's going to call on me. All right. So, okay, yes. So actually Zaid is asking, can we rely on non-pharmaceuticals in the managed care services? Yes, we're going to touch upon that in the next in the next couple of slides actually to show you, and it's all going to be part of what we call the STEP therapy management. Nisreen from Qatar, hi Nisreen, how are you? All right, so the first M is medication experts. Ta-da, pharmacists on here, right? So the first M would be medication, you being the medication experts, right? So that's of course, we're gonna just talk about that, which is important being the clinical pharmacists that you are. I'm also gonna talk about medication therapy management, as well as managed step therapy that I hinted upon when we first started the webinar. And of course, we can't go without talking about mail service pharmacy, because that is actually key and has been going on because of the COVID situation. So what else is here? Yeah. Yeah, please answer questions. So the panelists are saying even if it's a wrong— there's no right or wrong questions on here, right? So just your, your idea, your opinion, and it could be right, and if it's not exactly right, I would add on to it. No worries. So please feel free to step up and answer any of the— what you're understanding, because that, that will give me also what I need to sharpen you guys on if there's a misunderstanding about one point or another, right? So it kind of goes both ways, what I need to emphasize on so I could clarify even more, or if it's right, then I don't need to really emphasize and just go on to the next point. Yeah, so please, yeah, like I said, or the panel said, please, there's no wrong or right answers here. Okay, so medication experts. So how pharmacists can get involved in particular in the management of population health, provide patient-centered patient-centric care as an integral and valuable member of the healthcare team. Again, at the end of the day, it's a holistic approach. It's a— the healthcare system is also patient-centric, and we're part of that important team. And of course, medication experts that we are, not only medication, of course, we're going to see how managed care pharmacists not only worry about the medication, but every— someone mentioned already the non-pharmaceutical aspect as well. And we're going to talk about that important. So what is the cost and management of formulary development by what we call— I don't know if you ever heard of this terminology, but there's actually committees that managed care pharmacists sit on that are called the Pharmacy and Therapeutics Committees as well as the DUR committees. So I used to work in the heart of Manhattan at the biggest 320-bed hospital. And we— I was actually one of the managed care pharmacists who sat on that P&T committee. And of course, I was involved in both the therapeutics committee— sorry, the Pharmacy and Therapeutics Committee, as well as the DUR, Drug Utilization Review Committee. And what I specialized in actually was the cost and management of oncology combination regimens, because I was the chemotherapy pharmacist, if you will, at the hospital as well. And of course, as we all know, chemotherapy is very, very expensive. Some people don't even have insurance to cover it, and people who do have insurance, sometimes the insurance refuses to cover certain therapies, unfortunately. And all the— and the family, of course, would have to suffer because, you know, they sometimes— I see people selling their, their houses, their cars, their their life savings on these unfortunate chemotherapy because, of course, you know, at the end of the day, it's life-saving for these patients. So again, we as, as managed care pharmacists on these teams look out for that, understand that, and we need to do our best as healthcare professionals to be able to give the patient the opportunity and have that life-saving medication without actually having the whole family suffer or actually lose their life savings and so on and so forth. And sometimes not even being able to get the right care because of the finances situation. And of course, chemotherapy being the biggest, unfortunately, cost is of course important that we reduce that for our patients. So P&T committees are actually continually developing, managing, updating regularly formularies, as new medications and new information becomes available to us. And these committees are made up of, of course, managed care pharmacists, like I mentioned, physicians, nurses, and anyone who is part of the team actually that would be able to assist in, for example, a customized or a particular patient, or a specialist that would be able to assist the, the particular case, if you will, for a patient, or overall department that we're discussing depending on the committee's agenda for that day. So another thing that managed care pharmacists are part of is something called the DUR, or Drug Utilization Review, and I was very fortunate to be both part of this particular committee, and it is a comprehensive review of a patient's prescription as well as medical information in order to ensure patient safety and evaluate cost-saving opportunities related to medication. So of course, DUR, Drug Utilization Review, we want to make sure that the, of course, no side effects, no interactions, and everything is A-okay, that, you know, the patient's health, secondary conditions as well, is not going to be an issue with the medications. And reviewing all that part of the work that we do in the P&T as well as the DUR drug utilization review. But we're also looking at, again, like we mentioned earlier, that's always going to be a priority for us, and as well as giving the quality, as well as reducing the cost by contracting with third-party insurance, contracting with, with the pharmaceutical companies. So I'll give you guys an example. So I used to also work for something called National Pharmacy. This was actually owned by Merck Medco at the time in upstate New Jersey. In the US. So they actually— it was actually optimal because again, the pharmaceutical company was again the owner of the online pharmacy. It was online. We were actually dispensing medications mail order all across the US. And a lot of the employers or the organizations would contract with us. Why? Because it was a double savings for them. So they wouldn't have to worry about that middleman cost from the pharmaceutical to the pharmacy and dispensing and all that. And again, mail order would actually reduce also the cost of the employees. And, and all that cost savings would be giving back to not only the organization, but as well as the insurance companies that also reflected into the patient. Patient or the end user. And another thing that we did with this mail order Merck Medco company is we used to dispense 3 months supply. So if they had a blood pressure or maintenance drug or a chronic condition, we would be able to again— so the workforce was also reduced and so on and so forth. So when we dispense 3 months, the mail delivery, the stamp or the courier savings, so So you have, we saw it as a complete savings, not only for the third-party insurance, but again, for the end user. And of course, Merck Medco had all the medications. I mean, obviously we would be dispensing and recommending, or we didn't really only dispense Merck Medco medications. Of course, we filled the prescription as the doctor requested, but again, We also re-emphasize that there's also bigger savings with the, for example, Merck Medco drug versus a competitor, which again, we'd again be able to save even more for the patient and the third-party insurance or the organization. This is just an example of how managed care pharmacists, especially in DUR, drug utilization review committees, would be able to manage formularies like that. So managed care pharmacists play many, many roles. Okay, this is just a couple of examples that I gave you from my personal experience, but it also— they ensure patient safety because at the end of the day, I always emphasize that again, it's about the patient quality and of course compliance and end-user results, right? And of course, they're also conducting what we call drug utilization review, and I— and we, we went through that and we explained that. And they also serve on many of the pharmacy and therapeutic committees, especially in the US. We always have those, especially in hospital settings. And of course, we design and run medication therapy management programs. We'll talk about that in a bit because again, the clinical aspect has to be shown from what a managed care pharmacist does as well, and it's not just about the cost or administrative work. It's also we get— do get into the clinical management as well, and of course we also develop quality assurance programs. Okay, so what do I mean by quality assurance programs? Mohammed is saying we can detect the cost in chemotherapy by gene. Yeah, so there are certain research out there. Hanan Selim, hi. Okay, Dr. Baraik, I like to listen to you. Okay, Sattar, I'm not sure. So anyway, let's focus now on this particular question I'm posing to you guys. Okay, what have you guys ever heard of some quality assurance programs out there? So how do we— okay, so let's talk about formularies. Okay, have you ever heard of the, you know, the managed care services including formularies? I mean, I already touched base on that or spoke a little bit about that, where managed care pharmacies could actually create contracts between the pharmaceutical company as well as the third-party insurance or government sectors or public sectors or even private sectors, right? And at the end of the day, we want quality assurance programs. Yeah, so let's see if anybody has an answer. So Saktar is saying, uh, in many Arab countries, pharmacists have no authority to do that. To do what? To, uh, develop quality assurance programs? No, I don't think so. I mean, quality assurance is being able to pick and choose the, the products and services that would be not only cost— I've been saying it throughout the webinar— not only cost-effective but quality-effective as well. Yeah, so efficacy, yes, exactly, exactly. So without interfering medications, exactly, this is my point. Right, so that's what I mean. Quality assurance is your insurance, not only the cost-effective but also quality, right, that you get the end results for the patient who might be taking diabetes medication and make sure that the diabetes medication is quality, has all the bioavailability of the drugs or ingredients in there, and it does its job, right? So that's what we mean. It's very simple, but by the way, And we also create programs to detect, again, fraud, waste, and abuse of medications, which is actually not— I didn't do that per se when I worked on the DUR and the Pharmaceuticals and Therapeutics Committee. There was a different pharmacist that did that, but again, they were also a managed care pharmacist, and they were also part of the managed care team or services that we offered at the hospital. Okay, and of course, we designed drug benefit plans. Yeah, so again, like I mentioned with the Merck Medco Pharmacy Online and Mail Order Pharmacy, this is a drug benefit plan. What is a drug benefit plan? It's also third-party insurance or, or, um, an insurance or, or reducing out-of-pocket costs, if you will, for, for the patient. Yeah, so there's another, uh, got the drug to be safe and more effective. Muhammad, yes, exactly. That's what quality assurance programs is. Thank you, Mohammed, for interacting. And also we help clients evaluate and improve their pharmacy benefit. Okay, so there in community pharmacy, let me, let me, I'm always talking about hospital and clinical and all that. Let's take an example for community pharmacy. Okay, so in a community pharmacy, if for example, a patient comes in wanting calcium, All right, so you would take two products that you feel would be the same effect efficacy, the same bioavailability, and will get the same result for bone or for someone who wants calcium, right? So you would also tell and evaluate to the patient or to the client, okay, well, these are two products, but there's an offer on this particular, so it's buy one, get one, or something like that. They have that we've got sometimes here in, in Dubai and some pharmacies, right? And they have certain contracts with these manufacturers that offer these products. So which, which at the end of the day, you want to also improve your pharmacy benefit as well and, and profit, but also evaluate the products and be able to direct or ensure the client or patient gets also the value they're looking for and Of course, everybody wins in that situation. Yeah. Okay. So the next M is the medication therapy management. So what is medication management therapy? Excuse me. These are services that identify and address medication-related problems and medication mismanagement that help the patient understand proper medication usage. Certain patients are enrolled in these particular government services and employer-sponsored benefit plans that utilize this particular service to reduce, again, costs through patient adherence. So I gave that exact example when we dispense the 3-month supply for chronic conditions that the patient is already on for blood pressure or diabetes or wherever it is, right? So again, we enrolled these particular patients in this regular— and we were able, of course, in the US, you have to have something called refills. So if you go, sometimes doctors, if they've never seen you before, they'll give you one prescription without any ability for you to have a refill on this prescription or drug. So what we do in the managed care service that we utilize We again inform or give this service outline, if you will, or guidelines to our third-party insurance so that we ensure we educate also the patient so that when you— when they go to the doctor and they understand that this is going to be a lifetime medication that they're going to be on, to make sure you get the prescription to be able to be filled for 3 months, 6 months, wherever. Is allowed for your insurance carrier to approve. So all this guidelines, information, and, and ideas and, and plans that we put into place, it will actually benefit, and at the end of the day, the patient. Why? Because you would have adherence and compliance. So the patient will not, um, at the end of the day, we want to improve their health, want them to continue and taking their medication so there's no relapse or side effects or, or any of the counterintuitive or counteraction that they would get from stopping the medication, especially when it comes to serious conditions like high blood pressure, cardiovascular, and of course diabetes and so on, right? So this is one example, if you will, that would be a good idea to have a benefit plan that utilizes us as a managed care service that we allow patient adherence and compliance. And that's pretty much what it is in a nutshell for a managed care therapy management. Okay, so who does the medication therapy management benefit? Like I said, it's those patients that are on maintenance medication, and the ability actually for all the patients' medications and labs to make their excuse me, treatment better. And of course, this is patients who use several medications for multiple health conditions. Like I mentioned, if they have diabetes, high blood pressure, this would be the ideal patients that would be getting this service for managed care services. And people would take medications that will require careful monitoring as well. And of course, the patients actually change from one healthcare setting to another, such as from the from the hospital to the home or from the home to a long-term care facility. And of course, in the US it's actually communicated and this always follows with their records via technology. But I understand some Arab countries or some other countries, this might not be possible and a medical report will always have to follow on a paper format with the patient. But again, it's no different whether it's manual or through technology. But at the end of the day, these are the patients we're concerned about when we're looking to apply these important managed care services and therapy management benefits in particular. And of course, the pharmacies— and I'm from Egypt, right? So it depends. You know, in Egypt, the patient doesn't care. I mean, if it's on their way to work or on their way home or, you know, they a friend can pick it up for them from different, different pharmacies. And if they're not really— they're going to multiple pharmacies, and again, the record is not there. So there is no pharmacist that from this pharmacy that's going to tell the other pharmacy, oh, be careful, you know, they got the generic from us, so they're getting the brand name from another pharmacies. And there's, of course, always this confusion until they happen to go to the— to their doctor or physician and they show the medications to them. They're like, oh my God, you're taking two of the same drugs. And I, you know, it's always an issue in that situation when patients are going to many, many different pharmacies and not going strictly to one pharmacy to get their medications. And again, this is one of the advantages of therapy management for a managed care pharmacist to notice and take care, especially if they have a system that does this automatically for them. And someone earlier said, what about non-pharmaceutical intervention? So this is the part where we're going to talk about that right now. Let me just see who's on here. So Zaid is saying chronic and post-operative conditions are subject to medical care and pharmaceutical supervision only in these cases, or these weaknesses in the subject. Okay, uh, drug, drug interactions, Muhammad. Uh, what are disadvantages of, um, yeah, so this is what I'm saying. I think we just did the disadvantages, uh, right here. And this is why the advantage of having the MTM benefit, uh, is for these particular— it's not restricted only to these, um, group of patients, but again, uh, and in general terms, these are the patients that we need to be careful with when we're on the need for therapy management benefits. Okay? So managed step therapy here is actually the use of proven clinically effective prescription prior to trying a medication with less evidence that might have less evidence of effect, clinical effectiveness, or higher cost, especially with the launch of the COVID-19 vaccines. Okay? So managed care pharmacies determine if a medication is preferred based on effectiveness, safety, and of course cost. And step therapy actually requires the use of a preferred medication prior to beginning another medication for the same condition or in the same therapeutic class. So I'm going to give you guys a question or a condition that you would then be able to tell me what are some of the steps therapy that you would use if you were a managed care pharmacist in that situation. But let me just explain again what that exactly means, and this may require the use of medication different from what was originally prescribed after talking to the prescriber. Of course, I understand that, you know, pharmacists sometimes don't have just the ability to change the medication for the patients And the patient always has the option to pay for the original prescription medication prescribed without using the prescription benefit or the alternative, if you will, or the generic, whatever title that you're familiar with. And also the prescriber can provide additional information about the patient's medical history, which may result in the original prescription being approved. Again, if we're talking about third-party insurance. So let's take an example now for what we talk about managed step therapy. Okay, so let's say, is that the next slide or? Yeah, here's the example. Okay, so let's step therapy, let's talk about diabetes. Okay, so a patient is newly diagnosed with diabetes. So from your experience or knowledge or understanding, what do you think would be an example of a STEP therapy for the diabetes patient? After we have diagnosis and monitoring, we give supported self-management, non-pharmacological management— someone already mentioned that— minimal cost and invasive minimal invasive measures. And of course, what would be the recommended first line of therapy? And if we need be, we increase the dosing and management of that therapy. And of course, we continue to monitor the medication therapy management. And we want an example. What would be the first thing, number 1, as an example of a step therapy? Anyone? Once we have the diagnosing and we're monitoring now the patient who's newly diagnosed with diabetes, what would be the first supported self-management information? High blood pressure. Yeah, so Mustafa's right, lifestyle modification is the first step after Absolutely. For diabetes, yes, Ali, diabetes. Okay. Diet, yes. So that would be actually the non-pharmacological management, right? So diet, lifestyle modification, yeah. So what would be a supported self-management? So this is why I did this particular example is to understand the difference between supported self-management and non- non-pharmacological management. Okay, so Muktesh said check insulin rate. So what would that be? Would that be the non-pharmacological management or the supported self-management? Checking the insulin rate, for example, or the sugar level. Yeah, exactly, supported self-management. Perfect. So this is really important that I wanted one of the key examples or this particular in detail a little bit is because you would understand then or take away the difference between the supported self-management and non-pharmacological management. Okay. So what would be the next step? What would be the minimal cost non-invasive measure that would be prescribed for this newly diagnosed patient? With diabetes? Yes, thank you. Metformin, glucophage. Yeah, exactly. That would actually be the minimal cost and a non-invasive measure, right? That's like the number one. I've actually saw one particular research that in the This is like the number one first line of therapy for a lot of the— across the world, not just in the US or Europe. Okay, so that would be the minimal cost, metformin, and of course the recommended first line of therapy. Now, what would— well, when it comes to minimal cost, so we would have then glucophage or metformin, right? So obviously metformin, would be the cheaper or the least costly for that patient at that time, especially if he doesn't have health insurance. But then again, if he has health insurance and the third party pays for it, of course, you know, the patient would then have the option to get the glucophage. Yeah. So what would happen then? Would you— if the diabetes is still not controlled, even though you did the diet, the exercise, the lifestyle changes and all that. We went through all the step therapy, right? Would you be increasing the dose and management of metformin, or would you think the Amaryl or some— you would change them to insulin? Muhammad, what if he's not insulin dependent? Dr. Van Garde, very informative and interesting session. Thank you. Increase the dosing. So yeah, so, so you would increase, yeah, depending, of course, well, this is non-insulin-dependent diabetes, right? So that's correct. So then you would what? You would increase the metformin. Let's say he's taking 500 milligrams twice a day or 3 times a day. So you would what? Increasing it to 1 gram, or what would you do? Exactly. So perhaps you could incorporate the, the Glucophage combination, increase the dose to 750 milligrams. Of course, this is, um, just for an FYI. I mean, I'm not saying that we as pharmacists go ahead, but I— by the way, in the, in the U.S., in California where I'm licensed, I could actually prescribe just like a doctor in, um, with my license over there. So there are some states, uh, just for you guys to understand and, and know that a pharmacist, especially a clinical pharmacist who has their PhD and they're licensed as a, a PharmD license, you could actually prescribe, um, to patients and, and even recommend dosing adjustment and all that, that we're talking about here today. Yeah, I know in some Arab countries and some places that it's frowned upon that you always have to go to your primary physician for that, but just so you guys know that pharmacists do have the capability and the license to be able to do that, what we're doing here right now today. Yeah, all right, so that's pretty much it. Exactly, so you guys have the idea too, and then of course you would monitor test and measure the medication therapy management, which we spoke about in the earlier slides. Perfect. Okay, so we touched upon a little bit the last M here, which is of the 4 Ms we've been talking about, and that's mail service pharmacy. And I spoke a little bit about, about the, you know, the national pharmacy and the Merck Medco situation where we're then be able to send it out to to 3-month supply and of course create the formularies, right? So there is a huge need actually with the— and of course last year was always the pharmacy delivery service was also an important need and the option of actually receiving medicine and maintenance, especially medical supplies through the mail. It offers the convenience of course of the home delivery for maintaining prescription drug therapy as well at a lower cost. And I mentioned that earlier with the 3-month supply or 6-month supply for the patient to— and of course it creates the compliance as well. Chronic conditions often require long-term use of medications, so mail service pharmacies also help ensure patients receiving the medications in a timely manner to prevent gap between prescription refills, like I mentioned earlier. The ability of mail service pharmacies to purchase medications in larger quantities, as we were speaking about with the Merck Medco in particular, already having it in stock as a manufacturer, and may also allow these pharmacies to offer patients a lower cost or even copay or both. Okay. So there are really important benefits of mail order pharmacy. Medications are less expensive, and mail-order pharmacies operate through some health plans, third-party insurance actually plans, meaning that the insurer can buy medications in large quantities, not too large, like 3-month supply, and can directly from the drug manufacturer to lower the cost, as I mentioned with the mail-order National Pharmacy and the Merck situation, and usually contain a 90-day bulk supply which saves actually the patient's time, money, and of course improves patient compliance. So that means a 90-day supply, as we mentioned, for patients' prescriptions needs to be filled less often, so it's less time and work for the refills. And of course, many mail-order pharmacies offer 24/7 services through their website or by telephone, and this is helpful for patients as well who have questions about their medication outside of, again, the business hours when local pharmacies, of course, are closed. So that's pretty much the 4 Ms and some ideas and food for thought about some crucial skills and important takeaways or food for thought, if you will, for the managed care pharmacy, especially for overall relieving the cost or lowering the cost and, of course, giving the higher quality and ensuring compliance with the patient. So it's always a win-win, and we're making it actually more and more patient-centric, giving them the information and the tools, if you will, to have that full holistic recovery in their health and well-being. So that's a wrap. If anybody has any questions, please let me know. I will be sharing this slides, whoever came on a bit late, with the panelists today, and they'll be able to, whoever wants it, send it out to you. All right, so, so Mukhtar says we can do that here in Saudi Arabia. I'm assuming that you're able to adjust the dosing is what you're referring to. Yeah, so if there are any questions, yes, please, as the panelists have said, on this topic feel free to ask us. We still have some time. Yeah, we do actually, we have quite 8 minutes. All right, so Sotar saying low price company, what does that mean? I think this was previous to the step therapy question we were asking about, so So Muhammad from Egypt. Okay, so I just opened that here. I just saw there's a Q&A, uh, button, and everybody was just introducing themselves on here. Good communication. Okay, thank you. Yeah, so Zed was saying we can rely on non-pharmaceutical in the management. Is there any replacement for chemotherapy like radiation? Well, that goes back to the condition of the patient, Mukhtar. Yeah. What are some NTM disadvantages? Yeah, we covered that as well. All right. So can we use house pharmacy techniques for following up like in case of chronic conditioning? What do you mean house pharmacy techniques? Mustafa saying— sorry, saying nice lecture. Thank you. Thank you. For monitoring parameters. Yeah, so if we're talking, uh, like blood pressure, yeah, so you have the— I don't understand monitoring parameters, I guess. Okay, Ali's saying the role of community pharmacy is limited because of the government regulations. What differs from a country to a country? Yeah, so well, there is different regulation. Well, in the U.S. even each state has different, uh, even though it's the same country So each state allows certain privileges, if you will, for a licensed pharmacist who has a 4-year degree versus a PharmD, for example. So with a PharmD, you're really a clinical pharmacist, right? So you have the extra knowledge, if you will, or training that will allow you to use that in a clinical setting and be able to have, be able to prescribe or even, you know, change dosing and things like that. So I'm not saying all of the U.S. even, but I'm saying certain states like California and Florida, if you're a licensed pharmacist there, you have more privileges and more tools that you could use to help your patient. So Hanan Selim says, uh, great lecture. Thank you, Dr. Hanan. You're welcome. Thank you so much. Mustafa, going their home instead of they come to pharmacy or hospital, I mean. Okay, uh, so if you're prescribing something for a patient who's going home instead of them coming to your pharmacy or hospital, I'm still not understanding. Sorry. Sorry, Mustafa, uh, maybe you could share the question, um, to the panelists and I'll be able to send you a full, um, uh, response via email, inshallah. Okay, all right, so I guess no more questions. Thank you guys so much for joining us today, and hopefully I'll see you guys on our next webinar, inshallah.