PBM contracting

Linda Cahn makes some salient points in her article on decreasing prescription costs [“How to Dramatically Decrease Your MCO’s Rx Coverage Costs,” April.]

First and foremost, every MCO should understand what motivates its PBM. How does your PBM make money? Does it own and sell drugs through a mail order, retail, or specialty pharmacy? Utilization is the driver of any MCO’s drug spend. If the PBM’s bottom line is enhanced by selling more drugs, will it really be motivated to lower this trend? Just some other points to consider.

Dawn Anderson
Vice President
MedImpact Healthcare Systems
San Diego, Calif.

Unfair to pharmacies

The article on e-prescribing in the February 2008 edition [“Why Is It So Tough to Deliver on E-Prescribing’s Promise?] completely overlooked an important fact. E-prescribing costs the receiving pharmacy for each and every prescription received.

Physicians will have one-time costs for software and training. They will not be charged for transmitting prescriptions. Pharmacies will pay for each prescription received.

Medicare Part D has already forced the closure of many independent pharmacies because of inadequate and delayed payments. How can an independent pharmacy afford to pay for each prescription received in addition to paying for the transmission of each claim to an insurer?

Many more pharmacies will be forced out of business or forced to stop serving Medicare Part D patients by the mandate of e-prescribing without funding and sustaining implementation.

If there are proposals for incentives and rewards for physicians to implement e-prescribing, why not to the pharmacies that have to have software changed to accept the prescriptions? This cost should not have to be borne by pharmacy alone.

Pharmacists will still be on the phone to physicians’ offices with questions about prescriptions. The electronic prescribing systems in place now leave plenty of room for inaccuracies and problems.

We won’t be calling about the handwriting, but inadvertent changes in strength or directions, quantities that don’t make sense, product description that doesn’t match prescribed size, even choice of wrong medication all take place.

I see a great potential for e-prescribing, but also a great unfairness in placing the cost burden on physician practices and pharmacies.

Julie Schrantz, RPh
Director of Pharmacy Services
Clinton Memorial Hospital
Saint Johns, Mich.

Where are the data?

I read your article in the February 2008 magazine called “What’s the ROI on Wellness?”

What was interesting is that the companies that are providing the wellness programs had no data to support their claim of positive results.

I do not doubt that their programs are reducing health care costs but want to make you aware that there is a program out there that is actually documenting cost savings by companies when they set up programs using pharmacists as “coaches.”

The American Pharmacists Association Foundation (www. aphafoundation.org) started the Diabetes Ten Cities Challenge in 2005.

There are published papers about the actual cost savings involved in the Asheville Project, a diabetes self-management program started 10 years ago by the APhA Foundation that has proven to improve overall health, reduce absenteeism, shorten hospital stays, and reduce health care costs. I hope that you will consider doing an article about this progressive program.

I am a provider pharmacist in the Maryland P3 program, which is part of the Ten Cities Challenge.

I am learning first hand what a difference we can make in people’s lives.

Linda M. Smith, RPh,
Pharmacy consultant
Silver Spring, Md.

(Editor’s note: I guess you missed our cover story, “Asheville’s Legacy,” in the October 2007 issue.

No more patches

It is interesting that WellPoint cannot afford to pay providers more, inasmuch as their 2006 annual report stated a profit of over $3 billion [“How Doctors Are Paid Now, and Why It Has to Change,” December 2007]. Yes, $3 billion with a “B.” United’s “scandal” over the CEO’s income is right up there with Enron’s.

The sustainable growth rate (SGR) formula is a farce that needs a fix every year. This time Congress only deferred the consequences. The long-term effect for the nation in underpaying physicians is increased specialists, refusal to see Medicaid and Medicare patients, and lack of access for all.

The nation needs a complete solution to health care, not patches. One thought is to go to a single standard setter for policies and to institute uniform claims practices.

This would reduce the variation among policies and reimbursement, lowering the cost of providing care.

By eliminating the waste in the system caused by billing and reimbursement practices, we could increase coverage by 5 percent to 10 percent. The problem is that there are too many vested interests in the current system to change. The government should get out of the insurance business but retain the power to set minimum coverage and claim processing arrangements.

When I entered the health care field nearly 40 years ago, physicians were among the wealthier individuals in the community. All providers were expected to share in the care of the poor.

What health insurance there was, was often a high- deductible indemnity plan. But we were able to make it and continue to add to the technology and knowledge base.

We have gotten better at rendering care, but the influx of money into the system has not resolved some long-standing problems. For example, we can keep a person on dialysis for 10 years or more, but we have not resolved the issues with tissue rejection that might allow a person to be free of the machine.

Arguing among ourselves over who gets to keep the profits seems wrong.

R. W. Sorrell Sr., MBA
Senior Financial Analyst
Adena Health System
Chillicothe, Ohio

Managed Care’s Top Ten Articles of 2016

There’s a lot more going on in health care than mergers (Aetna-Humana, Anthem-Cigna) creating huge players. Hundreds of insurers operate in 50 different states. Self-insured employers, ACA public exchanges, Medicare Advantage, and Medicaid managed care plans crowd an increasingly complex market.

Major health care players are determined to make health information exchanges (HIEs) work. The push toward value-based payment alone almost guarantees that HIEs will be tweaked, poked, prodded, and overhauled until they deliver on their promise. The goal: straight talk from and among tech systems.

They bring a different mindset. They’re willing to work in teams and focus on the sort of evidence-based medicine that can guide health care’s transformation into a system based on value. One question: How well will this new generation of data-driven MDs deal with patients?

The surge of new MS treatments have been for the relapsing-remitting form of the disease. There’s hope for sufferers of a different form of MS. By homing in on CD20-positive B cells, ocrelizumab is able to knock them out and other aberrant B cells circulating in the bloodstream.

A flood of tests have insurers ramping up prior authorization and utilization review. Information overload is a problem. As doctors struggle to keep up, health plans need to get ahead of the development of the technology in order to successfully manage genetic testing appropriately.

Having the data is one thing. Knowing how to use it is another. Applying its computational power to the data, a company called RowdMap puts providers into high-, medium-, and low-value buckets compared with peers in their markets, using specific benchmarks to show why outliers differ from the norm.
Competition among manufacturers, industry consolidation, and capitalization on me-too drugs are cranking up generic and branded drug prices. This increase has compelled PBMs, health plan sponsors, and retail pharmacies to find novel ways to turn a profit, often at the expense of the consumer.
The development of recombinant DNA and other technologies has added a new dimension to care. These medications have revolutionized the treatment of rheumatoid arthritis and many of the other 80 or so autoimmune diseases. But they can be budget busters and have a tricky side effect profile.

Shelley Slade
Vogel, Slade & Goldstein

Hub programs have emerged as a profitable new line of business in the sales and distribution side of the pharmaceutical industry that has got more than its fair share of wheeling and dealing. But they spell trouble if they spark collusion, threaten patients, or waste federal dollars.

More companies are self-insuring—and it’s not just large employers that are striking out on their own. The percentage of employers who fully self-insure increased by 44% in 1999 to 63% in 2015. Self-insurance may give employers more control over benefit packages, and stop-loss protects them against uncapped liability.