In a session at AMCP Nexus 2025, thought leaders emphasized how research and evidence generation remain the backbone of managed care decision-making. The session, led by Pranav M. Patel, PharmD, MS, Drake Reiter, PharmD, and Chelsea Renfro, PharmD, highlighted the essential role of managed care pharmacists in interpreting data, balancing competing priorities, and transforming clinical findings into actionable population health strategies. Through a series of interactive case studies and breakout discussions, participants examined how evidence informs policy, formulary management, and patient care programs.

Patel began by framing research as more than an academic pursuit. He described it as a practical mechanism to achieve better health outcomes, stressing that data and evidence must inform every managed care decision. From determining whether to cover a product, to identifying the patient populations who will benefit most, pharmacists must navigate a complex intersection of cost, access, and quality. Patel noted that effective research demonstrates the value of products and services, identifies gaps in care, and differentiates therapies in crowded therapeutic markets. It also helps health systems uncover opportunities for quality improvement and population health advancement. Patel underscored that publication is not the end goal but rather a step toward operational change.

He described how managed care stakeholders—health plans, pharmacy benefit managers (PBMs), manufacturers, and providers—often interpret the same data through different lenses. Understanding these perspectives is key to collaboration and alignment. Patel outlined a process that begins with research, moves through quality assessment and bias evaluation, and then translates data-driven insights into decisions that ultimately affect patients and providers.

Picking up from Patel’s foundation, Reiter guided the audience through a series of case studies designed to illustrate this translation in action. The first focused on a retrospective analysis of 90 000 adults with chronic kidney disease (CKD). The study showed that as CKD progresses, costs and hospitalizations rise sharply. Attendees were asked to consider what a managed care pharmacist should recommend to a regional health plan noticing increased CKD-related admissions. Responses varied from expanding medication coverage to developing disease management programs and improving care transitions. Reiter emphasized that there is rarely a single correct answer; rather, effective managed care relies on weighing multiple, evidence-based strategies to address complex clinical and financial challenges.

The second case study explored comparative evidence in diabetes management, comparing two hypothetical therapies with differing costs and A1C reductions. When presented only with raw cost and outcome data, many participants found it difficult to choose a preferred formulary option. However, once a cost-per-outcome analysis was introduced, nearly all attendees shifted their preference to the therapy demonstrating a lower cost per A1C reduction. Reiter used the exercise to demonstrate how health economic modeling provides a clearer view of value, which can guide coverage decisions, rebate negotiations, and patient care optimization. The example also underscored how different stakeholders—patients, payers, manufacturers, and providers—may weigh costs and benefits differently when interpreting the same evidence.

Following these exercises, Chelsea Renfro expanded the discussion to include research on patient and provider preferences. Using a hypothetical survey on ulcerative colitis treatment attributes, Renfro illustrated that patients and providers often prioritize different factors—patients tending to focus on cost and convenience, while providers emphasize long-term remission and clinical outcomes. This misalignment, she explained, can directly affect adherence and persistence. Integrating preference data into formulary and pathway decisions can enhance satisfaction and outcomes, but doing so at scale remains challenging. Renfro encouraged managed care pharmacists to advocate for tools and frameworks that make shared decision-making more feasible across health systems.

Renfro concluded with a real-world example drawn from a study of health system specialty pharmacy interventions aimed at reducing oral anticancer medication waste. Pharmacists who reviewed refill requests before renewal were able to avoid unnecessary prescription fills, resulting in significant cost savings for both health systems and payers. Attendees discussed which stakeholders should be engaged with such findings, with many suggesting payer partners and internal leadership as key audiences. The exercise demonstrated how operational research within a health system can yield measurable value and create opportunities for collaboration between payers and providers.

The session closed with breakout discussions, allowing participants to apply the “what, why, and now what” framework to additional case scenarios. By connecting scientific evidence to the realities of managed care, the session underscored that research should serve as a catalyst for actionable decision-making. For managed care professionals, the key takeaway was clear: evidence must move beyond publication and be translated into strategies that drive value-based coverage, optimize resource allocation, and improve patient outcomes. Leveraging high-quality data allows pharmacists and health systems to close gaps in care, strengthen formulary and policy decisions, and ensure that cost, quality, and access remain in balance across the continuum of care.

Reference

Patel P, Reiter D, Renfro C. Evidence to Impact: Turning Research into Real-World Decisions. Presented at: AMCP Nexus 2025; October 27-30; National Harbor, MD.