Choosing between a managed care residency and a fellowship: the struggles of a pharmacy student

By Tae J. Park

I’ll set the scene for you.

Maybe it will sound similar to what you (a current pharmacy student) are grappling with. You made it into pharmacy school. You’re at an elite academic institution with a renowned medical center and your professors and preceptors are the best of the best. They equipped you with more clinical pearls than you asked for and now you are off to a great start in your pharmacy career. There seems to be a big push at your school to pursue a clinical residency, and most students seem to be riding that wave. But only after memorizing the top 200 brand/generic drugs and learning which antibiotics cover Pseudomonas do you realize maybe clinical pharmacy isn’t really for you… so what now?

It’s a struggle that I, and a handful of my classmates, encountered about halfway through pharmacy school.  Luckily, there’s a whole different side to post-graduate opportunities: managed care residencies and fellowships. To the pondering student looking for other avenues, let me break it down for you.

What is a managed care residency?

Managed care can have a relatively loose definition depending on whom you ask. In this context, managed care refers to insurance companies and pharmacy benefit managers (PBMs). As such, a managed care residency is a post-graduate program taking place at these types of companies. These programs are typically 1 year.

What does a managed care resident do?

Insurance companies and PBMs are often very large companies, with many different departments dedicated to managing pharmacy insurance benefits. Accordingly, a managed care resident can expect to dip his/her feet in many of these departments throughout the residency in blocks, similar to rotation blocks during school. Some examples of departments/blocks include formulary management, drug utilization review and clinical programs. Post-residency, many people end up working in one of these specific departments. Some managed care residents may also end up working in administrative roles within hospital systems or health maintenance organizations (i.e. formulary management at Kaiser), or even switch over to an industry role that is focused on negotiating with managed care companies.

What is a fellowship?

A fellowship is a broad umbrella term for a post-graduate program that usually takes place in the pharmaceutical industry (AKA drug manufacturers). But this is not always the case! There are also fellowships in academia and fellowships that are a hybrid of academia and the pharmaceutical industry, like the UW CHOICE fellowships. Fellowships are typically 2 years, although some are 1 year.

What does a fellow do?

Unlike managed care residencies, fellowships are usually offered by a specific department of a pharmaceutical company. A fellowship applicant can apply to a specific department, such as clinical development, regulatory affairs, medical communications, market access, or health economics. Depending on the company, departments can have slightly different names and some departments may have the term “managed care” in their titles (i.e. managed care medical affairs). This can be a bit confusing, but these are still departments within pharmaceutical companies and not payers. Rather, these departments are focused on communicating with managed care organizations for reimbursement and coverage purposes. Knowing which fellowship to apply to requires the applicant to have some prior knowledge of what department he/she is interested in.

In the case of academic fellowships, they are often specialized in a certain field of study and tied to an academic institution with a medical center. These fellowships are focused on conducting original research for publication and guiding treatment decisions. Some fellowships in academia also involve didactic coursework that confers a degree upon completion. As mentioned previously, some fellowships are purely academic and others are a hybrid of academia and industry. The UW CHOICE fellowships are a great example of this, where fellows complete coursework and an academic thesis to earn an MS degree during the 1st year and then transition to industry during the 2nd year. It is important to note that not all fellowships require the applicant to have a pharmacy degree. Some fellowships are open to people with PhDs, MDs and other science degrees! It all depends on the department and what type of skill set they are looking for. From my experience, it seems like the fellowships that are focused on research & development are often open to applicants from different educational backgrounds.

How do you decide between a managed care residency or a fellowship?

If you’ve read this far, you may have noticed that managed care residencies and fellowships are really quite different. They take place in different settings, are focused on different things, and have different structures. One thing I have noticed is that many pharmacy schools and student organizations tend to lump them together and tell the students, “hey, all these non-clinical opportunities are over there” without going into much detail about what’s what.

So here’s the news: it takes some effort on your part to decide what you want to pursue. Sounds cliché? Totally. But there isn’t much of a way around it.

If you see a summer internship at an insurance company or a pharmaceutical company, apply! Get your feet wet and see what it’s like on the inside. Didn’t get an internship or missed the deadline to apply? That’s okay, too! See if your school offers rotation blocks in these settings. Didn’t get the rotation you wanted? You’re still in luck. Spend some time to reach out to people who have worked in the field or at specific departments and ask them about their experience. Set up a one-on-one call or chat over coffee. Does it sound appealing to you? Then maybe it’s for you. Didn’t reach out to anyone? Well then now it’s really on you. There’s no free lunch.

Let me dispel a common misconception: having a managed care internship or a pharmaceutical industry internship on your CV IS NOT a prerequisite for landing a residency or fellowship. Your ability to convey that you have spent the time and effort to get to know the field and how your skills and interests match that field is more important.

My own experience…

A lot of my own experiences served as inspiration for what you just read.  I knew during my second year in pharmacy school that clinical pharmacy probably wasn’t for me. So, I started exploring elsewhere. I joined AMCP and went to their events to meet and talk to alumni who had pursued non-clinical routes in managed care and industry. I also participated in the Pharmacy & Therapeutics competition. When it came time for my teammates to split up tasks, nobody wanted to do the economic portion. It was difficult and economics seemed like a different language. Cost-effectiveness huh? What in the world is an ICER? It all seemed like stuff that was never taught in school. Nevertheless, I decided to take on the economic portion and unexpectedly enjoyed it. I learned so much while creating and interpreting a budget impact model. I never knew Excel could do so many things and it was actually pretty cool. I learned that entire departments in pharmaceutical companies were dedicated to health economics and outcomes research (HEOR), and I became curious.

I tried applying to HEOR internships two years in a row. I never managed to get one. Nonetheless, my curiosity was piqued so I didn’t stop there. I was able to find an internship at a local health plan. I took on projects that were more economic-focused and performed many cost-effectiveness analyses for the health plan. When it came time to pick rotation sites, I saw that my school offered a research block with our health economics professor. So I took that block. I was the only student in my year to choose that block. And it was awesome! I didn’t have to wear scrubs and got to work in an office setting with an endless supply of coffee. I learned new skills that weren’t taught in class, such as creating different types of economic models and using new computer programs.

When it was time to start applying for fellowships, I naturally looked into HEOR fellowships. I was intimidated, knowing that I had never done an internship in HEOR while it seemed like many other applicants had. Though I did have some relevant experience in managed care, I knew that it was still distinctly different from HEOR. Both settings perform economic analyses on medications, but from very different perspectives and scales. Managed care evaluates all the different drugs that come to market on a very broad scale, while tailoring all evaluations to the health plan’s own patient population. HEOR is much more specialized in economic evaluations and analyzes the company’s specific drugs on a deeper level for internal use while taking a national or global perspective. In some ways the skills used in managed care and HEOR overlap, but the perspective from which those skills are applied and the target audiences are different. I made sure to speak to this distinction while also highlighting how my experiences in managed care would be transferable to HEOR. I ended up choosing the CHOICE fellowship because I loved its hybrid structure—1 year in academia and 1 year in industry. Shameless plug: it’s pretty great and you should apply!

So, to the pharmacy student considering a managed care residency or fellowship, I recommend that you start exploring. And try not to fixate on just finding the exact internship you want. There’s plenty of other ways to get exposure—you just need to keep an open mind.

TLDR; check out the awesome pamphlet that Kevin Li, a current pharmacy student, made!

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