Increasing Value in Managed Care Practice

Question 1

What is a managed care organization (MCO)?

Answer 1

Organizations which utilize techniques to provide health care in a COST-EFFECTIVE manner.

AKA health insurance plans

Question 2

What is the difference between Staff model and Independent Practice Association (IPA) model MCOs?

Answer 2

Staff Model = physicians/clinics/hospitals EXCLUSIVE to enrollees

IPA model = MCO contracts with independent providers into their preferred provider organization (PPO)

Question 3

What are 4 types of MCO plans? (Aka how do people get coverage?)

Answer 3

Medicaid
Medicare
Employer-offered commercial plans
Self-funded plans

Question 4

What is the “triple aim” of MCOs?

Answer 4

Improve:
QUALITY of life
Patient SATISFACTION
AFFORDABILITY

Question 5

What is the organization that “measures” MCOs for quality?

Answer 5

Health Plan Employer Data & Information Set (HEDIS)

Question 6

What do PBMs do?

Answer 6

Claims processing
Assist with formularies
Review prior authorization requests
Pharmacy network administration

Question 7

______ dollars spent n prescription drugs in the US

Answer 7

400 billion!!

Question 8

How do drastically increasing prescription costs affect patients?

Answer 8

Increased insurance premiums
Increased copay costs => decreased adherence!

Question 9

What drives up drug utilization?

Answer 9

Improved technology (causes MORE, BETTER diagnoses!)
Guideline changes over time (usually dont consider cost, only clinical effect)

Question 10

How do drug manufacturers influence the drug market and utilization?

Answer 10

Manufacturers are free to set pricing at any number!
Price increases happen annually
Historically there have been very few interventions from government (have to face lobbying)

Question 11

What is patient solicitation?

Answer 11

Pharma manufacturers put out lots and lots of advertising DIRECTLY to consumers to influence prescribing.

Drug coupons reduce costs for patients but increase overall medication cost (money comes from here!)

Question 12

WHO is the biggest influencer of drug costs?

Answer 12

PBMs!
(Few, large PBMs have lots of negotiating power, demand high rebates)

Question 13

What are ACCELERATED FDA approvals?

Answer 13

Pathway for companies to get unique medications to market faster

Drugs MAY NOT be as efficacious as anticipated

Question 14

How do MCOs manage medications?

Answer 14

Formularies
Benefit design
Utilization management
Drug Utilization Review (DURs)
Specialty medications
Generics
MTM
Price transparency
Disease management programs
Rebates

Question 15

What is the difference between open vs closed formularies?

Answer 15

Open = all drugs are technically available
Closed = only listed drugs are available

Question 16

What is a P&T Committee?

Answer 16

Pharmacy & Therapeutics (P&T) Committee is comprised of practicing physicians and pharmacists
Develops the formulary tiers, recommend utilization
Meet quarterly to review newly approved meds
Review coverage of drug classes routinely to ensure cost-effectiveness
Ensure no biases

Question 17

What are the major factors that the P&T committee consider? What is the NUMBER ONE objective?

Answer 17

SAFETY and EFFICACY
The NEED for the drug
EFFECTS on clinical outcomes
Multiple products in a class
Physician ACCEPTANCE

OBJECTIVE = overall cost effectiveness

Question 18

What are the formulary tiers?

Answer 18

Tier 1 = generic drugs, preferred!
Tier 2 = brands w clinical advantages, $$ first line therapies, unique approved therapies
Tier 3 = me too drugs, non-preferred drugs

Question 19

What are some ways to affect the actual insurance plan costs?

Answer 19

Reduce coverage
Increase employee contribution aka premium
Shift to incentivized benefit design (ie. Tiered formularies)
Coinsurance (% copay instead of flat cost)
Min/Max per prescription
High deductibles
Out of pocket maximums

Question 20

What are prior authorizations?

Answer 20

Basically a petition to get a non-preferred drug covered
Paperwork must be submitted by provider
Helps verify appropriate use and safety
Usually turnaround is <24 hrs

Question 21

What is step therapy?

Answer 21

Requires patients try certain preferred medications before insurance will cover a different non-preferred agent

Question 22

What are quantity limits and why are they used?

Answer 22

Limits number of drug allowed to be billed
(May be limited per fill, time period, or per lifetime
Either due to package size or clinical limits (ie. Abx should only be used short term)

Question 23

What is diagnosis editing?

Answer 23

Uses medical claims data to automatically review claims for appropriateness in real-time
Helps curb inappropriate use

MOSTLY FOR GLP1 DRUGS TO PREVENT USE FOR WEIGHT LOSS

Question 24

What is a retrospective DUR?

Answer 24

Review of past claims history to identify concerns
- opioid/benzo use
- indications for high dose opioids
- gaps in antipsychotics or HIV therapy

Question 25

What kind of medications are usually specialty meds?

Answer 25

Biotech products that target patients with complex therapies

Question 26

What are some considerations for specialty medications?

Answer 26

May have coverage under either medical benefit or prescription drug manufacturer
May require additional dose/ side effect monitoring, administration help
Management of OFF LABEL use with clinical evidence

Question 27

Which is more expensive, pharmacy benefit (patient administered) or medical benefit (clinician administered) specialty meds?

Answer 27

PHARMACY benefit (PATIENT administered) specialty meds cost more! Fastest rising portion of Rx cost

(Medical benefit/clinician administered costs is usually from cancer-related treatments)

Question 28

What is the name of the policy that forces patients to use generic drugs before brands?

Answer 28

Generic First Policy

Question 29

What are biosimilars?

Answer 29

A biologic drug that is nearly identical to an existing biologic drug
AKA similar but not equivalent to generic
(Potential for savings but not substitutable at pharmacies!)

Question 30

What is academic detailing?

Answer 30

Providing prescribers with cost vs efficacy data (including medical costs)
Counteracts any misleading advertising from manufacturers

Question 31

What is MTM?

Answer 31

Medication Therapy Management
- CMS requires insurers to have an MTM program in place of Medicare D
- Complete annual review of medications and quarterly follow ups
Complex drug regimen patients have better outcomes with MTMs