Case Examples Flashcards
Coalition - Pricing Case
SITUATION
I led the RFP response process for a newly launched coalition designed to drive new business growth.
Since the coalition had not yet gone into effect, I did not have access to actual historical claims data or real-life enrollment statistics
I also had to work through ambiguous requirements to identify key potential expenses such as dedicated human resources
TASK
I formulated a pricing strategy for a client with very limited data available.
ACTION
I searched and screened our book of business for relevant comps. I utilized the benchmark data in place of actual client specific data
I created multiple projections based on possible business outlook and client’s estimates for program enrollment. Then I formed a weighted P&L based on likelihood of meeting those target estimates.
Pared down costs by identifying areas where we can leverage overlapping functions of dedicated resources
RESULT
The client Invited us to the finalist round based on strong financials in comparison to other participants
Proposed financials yielded 3-4% higher savings than leading competitors, while still maintaining positive net operating margin”
LESSON LEARNED
To have bias for action, creative problem solving, assumptions based on sound logic
Contracting SOP
SITUATION
I created and implemented a new standard operating procedure for our Business Development team’s contract administration process. There was no previous structure in place, which led to many delays, miscommunications, and errors in the process.
TASK
I needed to develop a firm foundation and framework that would work for every direct contract opportunity.
ACTION
First, I created a complete workflow chart connecting multiple swim lanes, including the Business, Finance, and Legal teams. This allowed me to find areas for optimization and set specific timelines to address the delays
I documented and standardized the step-by-step process including contract intake, business reviews, redline and version control, and approval and signature process.
I established weekly checkpoints connecting the stakeholders to discuss outstanding contracts to facilitate consistent updates and communication.
I leveraged an internal contracting system in order to ensure proper version control and documented approval and signature process.
RESULT
This project helped significantly improve and optimize the contract execution process and streamlined compliance. As a result, the Biz Dev team was able to execute over 100 key direct contracts and amendments with 6 additional payer partners in the past year, a Y-o-Y improvement of +150%, highlighted by our agreement with a large Payer to be their exclusive home delivery partner, which will add an additional 4.8MM eligible lives.
Data Reporting and Performance Tracking
SITUATION
There were too many discrepancies and unreliable data available to our team to utilize for Biz Dev strategy
TASK
I needed to establish accurate data reporting and performance tracking capabilities of each of our Payers
ACTION
I worked with the Finance team to align on how they were calculating their metrics in assessing contracts, reimbursement rates, utilization, vendor profit, etc. I worked with the Strategic Ops team to develop an automated reporting system using internal pharmacy data
RESULT
Created a combined report that now acts as the source of truth for our team in decision making for multiple lines of businesses, including Commercial, Medicare, and Medicaid
Lower Net Cost of Care Strategy
SITUATION
During my time at Elevance, I implemented a strategy on pushing for the lowest net cost of care formularies to differentiate ourselves from our competitors in hopes of winning additional business from plans that emphasized service and quality of care. For context, across all payers, manufacturer rebates as a percentage of total drug spend was around 18% [24% for brand drugs and 13% for specialty drugs]. Rebates are pricing concessions paid by manufacturers, primarily for brand name drugs, in exchange for placing the drug on the payer’s preferred drug list. Traditionally, we approached each bid with the most aggressive rebate guarantee offer like everyone else in the market. As I met with various stakeholders, including the pricing teams, sales and account management teams, as well as the clinical strategy teams, I was faced with differing opinions on which methodology would be best utilized for our health plan clients.
TASK
The ultimate objective we shared as a team was to effectively improve on 1) the rate of finalist invitations we received and 2) the close rate on the bids we participated in. While we all agreed on the end objective, I still needed to deal with convincing my colleagues and leadership on utilizing the lowest net cost of care approach.
ACTION
To deal with the task, I first clearly outlined the key differences between the methodologies so that all members of the team involved in the RFPs understood the options under consideration. I analyzed 100 test groups to calculate the percentage difference between higher rebate formulary offers vs. the lower net cost of care offers, which came out to 2.7% lower drug spend when utilizing the latter. I then use the results of the analysis to put together a case study to be implemented into the overall sales pitch to illustrate the unique value our organization was bringing to the table. I also highlighted the positive impact lower-cost generic alternatives had on improved adherence of patients.
RESULT
In the following standalone/health plan RFPs we participated in, we were invited to an additional 8 finalist meetings, a 62% improvement from the previous bid season. The new presentation highlighting the value add allowed us to stand out from a service and patient focus perspective. This also led to 4 additional wins, a 133% improvement.
LESSON LEARNED
Working together on a team towards a common goal is always more successful when everyone is on the same page. It enables fast decision-making, more efficient problem-solving, and better communication throughout the process. There is greater buy-in when you have the understanding that every opinion is valid and valued.
Manufacturer Rebate Model
SITUATION
During the first few months with Elenvance, I gathered negative feedback from several colleagues on the previous process and tool used to project manufacturer rebates. I validated the feedback by running test cases (sample size of 20 of varying lives count, lines of business, pricing teams (standalone vs. integrated)) and identified the biggest issues to address as 1) inaccurate results; 2) process speed; and 3) scalability (more user cases, better process to keep latest and updated information), and flexibility. I created a high level plan for a solution and brought recommendations to leadership.
TASK
I needed to create a better system/model that addressed all three of the biggest issues and problems with the previous process.
ACTION
I created a process flow chart and project management plan with defined goals/objectives, requirements, and deadlines. I defined the roles and responsibilities for each team member. I overcame the lack of development resources by leveraging previous technical skills of the team. I built the working product and executed through the subset phases to ensure deadlines were met. I tested against program requirements for quality and accuracy. Following several rounds of through testing, I launched new tool to all pricing teams and also led training efforts across organization
RESULT
Effectively reduced variance between projections and actuals to single digit percentage (3-6% variance from actuals vs. 5-12% in previous model). Improved process speed from 30+ mins to under 4 mins per scenario. Implemented periodic updates and testing schedules to easily keep latest metrics within the tool. Added functionality to expand customization of pricing (specialty list, output options, increased assumptions)
Multi-departmental RFP Response Database
SITUATION
Our organization was new to standalone pricing processes and RFP opportunities. We needed a system to control for redundancies and inefficiencies in responding to standard RFP questionnaires.
TASK
Create a method in which we can simplify RFP response process and maintain consistencies in our responses.
ACTION
I developed a database in Excel of all previous questions and response requests from various consultants and clients. I organized to match guidelines based on metrics such as client size, scripts PMPM, consultant, pricing structure, network request, etc. I further developed the database along with RFP Proposals team to expand beyond finance related questions.
RESULT
Reduced required RFP response timing from 5 days to 2 – removed reliance on other departments for correct data. Made the task easier for other teams as they can just pull the responses from the database instead of waiting on SMEs. Improved adherence and consistency in RFP responses – qualitative scoring resulting in top 2-3 respondents. Mapping out response and tracking also made it easier to see where we can improve our process and be more customer focused / compliant with request.
Network Configuration Correction
SITUATION
I faced an issue with an incorrect pharmacy network set-up due to error in benefit coding. The issue was identified after the effective date of the contract and the customer had already begun receiving benefits under the wrong configuration and as a result were overpaying on services.
TASK
Although the Pricing team was no longer involved in the process, I led the efforts in implementing the correct network configuration and communicating the changes to the customer.
ACTION
First, I tracked the entire process workflow to identify the point of error and started mobilizing necessary departments to fix it. I was able to identify the root cause as an error in coding in one of the databases used to relay benefit design information to the networks team. I then clearly outlined a course of action to remediate the problem and worked with the networks team to update the configuration. Then I ran the complete analysis on member disruption and financial impact before working with the Sales and Account Management team to communicate the changes to the client and address any concerns or issues.
RESULT
In the end, we were able to maintain the customers’ trust in being transparent even when errors occur. Restored full financial value through credit back to the account in a timely manner. Communicated to members of the change and to address any concerns from an access point of view. Lastly, I identified and fixed the source of the problem by implementing a new checks system prior to onboarding to ensure the benefit coding matches the financial contract.
LESSON LEARNED
Communicating honestly applies to both internal and external stakeholders. It it difficult to accept feedback that you made an error or a mistake, but it is important to look for resolutions rather than being discouraged by the feedback.
State of New Jersey RFP
SITUATION
During my time at Truveris, our team received a request to facilitate an RFP for a very large scale and complex client. The client was a state government entity with over 750K public employees and dependents. My manager who was handling the task was pulled into other pressing priorities and asked for someone on the team to take on the lead role.
TASK
I decided to step up and take responsibility. I had been looking for an opportunity to prove that I can take on more complex and high visibility, client facing projects. I also wanted to help the company in a time of need.
ACTION
As I had to assume the role of lead consultant, I was the main point of contact for over 10 PBMs and vendors. I led all the training efforts to communicate specific RFP instructions and usage of our online platform.
I worked with the development team to meet the clients’ requst for custom terms and built new functions in our system in order to meet full compliance.
Lastly, I ensured the financial outputs were accurate based on submitted proposals and produce presentation material.
RESULT
As a result, we were successfully able to provide the state with 3-year savings of approximately $1.5 billion or nearly 20% from their current drug spend. More importantly, it allowed members to maintain full pharmacy benefit coverage for themselves and their families.
Sudden Turns in Negotiations - Contracting Case
SITUATION
I had to work through an extensive negotiation process with a prospective client as they were not satisfied with the initial terms we had agreed upon during an RFP. This client was very small in size, with less than 1K covered lives. They requested changes to the terms including parts of the financial guarantees, payment schedule (accounting), and market check clause (legal/proposals). Although this client was relatively small, I really wanted to focus on developing our relationship and establishing trust, with not just the client, but with the consultant and broker that we were working with for the first time.
TASK
The challenge I faced was maintaining the integrity of the RFP terms and agreements, while being customer focused and compromising in areas, so that we can provide exceptional service.
ACTION
I worked with various departments to understand the full impact of each revision requested by the client. I reconstructed the financial offer to allow for additional credits and reimbursements to provide the client with greater value.
RESULT
As a result, I was able to successfully finalize our first standalone contract through this key consultant. Furthermore, our focus on customer satisfaction led to positive references and led us to receive an additional 10 bid invitations in the following months.
Truveris Platform Redesign
SITUATION
Proprietary software platform used to configure and run RFPs online, rather than spreadsheeting.
Identified inefficiencies in the process flow
○ Unnecessary dependencies between pages
○ Learning curve steep for new users as backend coding knowledge was necessary to troubleshoot and manipulate data
○ Reliant on old legacy software for TruGuard, which served a completely different purpose
TASK
Redesign the platform and create a standalone version
ACTION
Mapped out the process flow to identify points and step where it could either be eliminated or pared down with a similar step
● Completely separated the platform from legacy product to avoid “patching” up the solution and remove confusing steps
● Worked closely with the Developers and UX UI Team to translate coding and technical aspects to more user friendly version for the operations team
RESULT
User interface became sleeker and much easier to use for all parties involved (analysts, external vendors)
● Able to add on new functionality for reporting and custom cases due to new design”
