Medical Vs. Pharmacy – Benefit Considerations for Benefit Checking and Reimbursement Models

Medical vs. Pharmacy – Benefit Considerations for Benefit Checking and Reimbursement Models Electronic Beneﬁt Veriﬁcation & Information Exchange May 18, 2016 | DoubleTree Center City | Philadelphia, PA Point-of-Care Partners | Proprietary and Confidential Speakers Anthony J Schueth Debbie Stern, RPh CEO & Managing Partner SVP Medical Oncology and Specialty Drug Management Point-of-Care Partners eviCore healthcare 954-346-1999| [email protected] 949-433-0847|[email protected] Point-of-Care Partners | Proprietary and Confidential 2 Agenda • The Current Environment • Eligibility and Benefit Verification Today • Medical Benefit • Pharmacy Benefit • Prior Authorization • Medical Benefit • Pharmacy Benefit • Where We’re Going Point-of-Care Partners | Proprietary and Confidential 3 Growth of Pharmacy Specialty Spend Specialty Drugs 2014 By 2019 • Used to treat chronic catastrophic illnesses like multiple sclerosis, hepatitis C & rheumatoid arthritis • Often injected or infused >1% of Rxs 32% or more of Nearly 50% of • Costly written for Pharmacy Plan Costs Pharmacy Plan Costs Specialty Drugs Source: Express Scripts Lab Point-of-Care Partners | Proprietary and Confidential 4 The Differences Between Pharmacy and Medical Medical Pharmacy Benefit Benefit Technology Can Bridge: Software/Tools Criteria Route down Medical or Pharmacy benefit Point-of-Care Partners | Proprietary and Confidential 6 The Current Environment – Pharmacy Benefit Point-of-Care Partners | Proprietary and Confidential 7 How Does the Pharmacy Benefit Work? • Self-Insured employers and health plans leverage third-party payers (TPAs) to manage the pharmacy benefit (called PBMs) • Specific functions of PBMs include: • Main drug formularies to manage utilization and costs • Create networks of contracted/discounted retail pharmacies • Process pharmacy claims • Negotiate drug rebates with pharmaceutical manufacturers • Provide mail-order pharmacy dispensing • Administer programs to help reduce drug spend for clients, including Drug Utilization Review and Compliance Management Programs Point-of-Care Partners | Proprietary and Confidential 8 Leveraging the ePrescribing Infrastructure 83% 700 95% 67% 58% Office-Based EHRs Enabled Pharmacies Enabled New Prescriptions Prescribers Utilizing for ePrescribing** Written Electronically** Electronic Prescribing** Physicians Use More than 700 EHRs Any EHR* enabled for ePrescribing *HealthIT.Gov **Surescripts Point-of-Care Partners | Proprietary and Confidential 9 Pharmacy Benefit Information not captured in the EHR Prescription benefit information is on member insurance cards but it is not typically captured by practice staff Most EHRs don’t have a mechanism of capturing the pharmacy benefit information. The main focus is on the medical data Despite significant progress with electronic formulary, practices still typically do not capture prescription benefit information from patients, as it is not used for the physician’s billing Point-of-Care Partners | Proprietary and Confidential 10 The Way ePrescribing Works Physician Practice PBM or Plan Request Eligibility, A1 Drug History Intermediary Claims Processing System EMR or eRx System benefit plan rules, formulary, Response A2 history Electronic transmission (EDI) Pharmacy B New Rx Refill Request Refill Auth/Denial Change Request C Pharmacy Dispensing System Drug info Formulary Pharmacy Database Database Directory Point-of-Care Partners | Proprietary and Confidential 11 Challenges with Eligibility-informed Formulary • Data tends to be at the Plan or Group level • Static data • Inconsistent use of standard • Potential inaccuracies • Lack of appropriate granularity Point-of-Care Partners | Proprietary and Confidential 12 Real-Time Pharmacy Benefit Inquiry Today and Pilots One Target, but currently many paths… • NCPDP workgroup efforts • Use Case Development • Industry Stakeholder Pilots • Modification of D.0 Telecommunications standard • Modification of SCRIPT standard • Proprietary connection • ONC and CMS requests for pilots Point-of-Care Partners | Proprietary and Confidential 13 Current Manual Prior Authorization Rx Pended/ Manual PA Begins If denied, pharmacist calls doctor who notifies patient, prescribes Doctor submits alternate therapy or the prescription submits as cash Rx. though normal ePrescribing flow. Pharmacy processes Rx, bills payer, dispenses Pharmacists spend an After approval, doctor or administers average of 5 submits electronic medication. hours/week on prior 40% prescription with authorizations. OF PRESCRIPTIONS authorization # to ARE ABANDONED pharmacy. Point-of-Care Partners | Proprietary and Confidential 14 Prior Authorization Impacts All Healthcare PHARMACY HASSLE PATIENT HASSLE AND • Pharmacy must call TREATMENT DELAY prescriber’s office, and • PA unknown until patient sometimes the plan has already left office Pharmacy • Treatment might be PRESCRIBER delayed for days HASSLE AND Patients DISRUPTION Prescribers Prior • Call back from pharmacy, must call Authorization plan, wait for faxed PHARMACEUTICAL form, completes form OBSTACLES Impact and sends it back • Delayed and • Turnaround time can abandoned be 48 hours or more prescriptions Pharmaceutical PBM/ Health Plan • Extensive outlay Co. for physician and patient PBM/HEALTH PLAN administrative INEFFICIENCY assistance • Expensive and labor intensive process that creates animosity Point-of-Care Partners | Proprietary and Confidential Interim PA Automation (non-ePA) PATIENT PAYER PATIENT • Workflow Visits Physician Automation PRESCRIBER PHARMACY • Payer/Multi-Payer • Rejection Code- Portals driven Workflow Until today, automation largely replicated the paper process requiring duplicate entry of information. Point-of-Care Partners | Proprietary and Confidential Gaps in Current PA Activities Drug requiring PA flagged in only 20% - 40% of the cases Criteria not residing within EHR or visible to physician Does not automate the entire process – various workarounds that may or may not meld together Paper forms and portals require manual reentry of data that may already reside electronically within an EMR Multiple routes to obtain PA depending on health plan, drug, pharmacy, and patient combination Point-of-Care Partners | Proprietary and Confidential Electronic Prior Authorization Update CoverMyMeds PA Growth • States driving adoption of ePA 9 • Retrospective and prospective models 8 emerging in the marketplace 7 • Industry movement toward prospective 6 5 • Prospective ePA officially approved as part of the SCRIPT standard in July, 4 2013 Millions 3 • Standardized retrospective process 2 on-hold 1 • Standardized questions being 0 2010 2011 2012 2013 2014 2015 addressed Pharmacy Physician • Need for standardization, evidence- based PA criteria Source: CoverMyMeds Point-of-Care Partners | Proprietary and Confidential 18 The Medical Benefit Point-of-Care Partners | Proprietary and Confidential 19 How Does the Medical Benefit Work? • Employer/individuals pay premium to health insurance plan • Drugs administered by a HCP are covered under the medical benefit • HCP may be MD office, hospital, home health or infusion provider, ambulatory infusion center • Medical benefit drug costs built into deductible, cost share and max out of pocket • Health plan management of medical benefit drugs • May create formularies across RX and medical to manage utilization and costs • Create networks of contracted providers (HCPs) with variable reimbursement rates for same drugs: MD, home infusion, Hospital • Process drug claims on legacy medical claims systems not built for prospective adjudication; not directly linked to providers • Lag in time between drug administration, billing and reimbursement • May negotiate drug rebates with pharmaceutical manufacturers • May require prior authorization or adherence to medical policies Point-of-Care Partners | Proprietary and Confidential 20 No e-Prescribing under Medical Benefit Buy and Bill • Order may be entered into EMR, but no “prescription” SP Distribution • Order typically faxed along with a statement of medical necessity • Either SP or MD will obtain Prior Authorization • SP will typically try to bill under RX benefit first, then medical benefit • Most payers lock out infused drugs from RX benefit • SPs typically prefer RX benefit, as they get instant verification of payment information and copay (if applicable) Point-of-Care Partners | Proprietary and Confidential Medical Benefit Process Flow – BUY AND BILL MD buys drug for Stock supply or HCP Pharma Direct patient or Wholesaler Patient Manual or through web Eligibility Subject to post service – may be multiple check MD bills HCP bills edits. inquiries and delays Drug + patient for Prior Admin Time gap between cost share authorization submission, post health authorization and plan payment payment Health Plan Point-of-Care Partners | Proprietary and Confidential 22 22 Medical Benefit Process Flow – SP Distribution MD orders drug for patient SP ships HCP Specialty drug to MD Pharmacy or patient SP bills Patient plan for Eligibility drug SP bills check MD bills Subject to post service patient for Manual or through web For edits. – may be multiple Prior Admin cost share Time gap between post health inquiries and delays authorization submission, authorization and plan payment payment Health Plan Point-of-Care Partners | Proprietary and Confidential 23 23 Mechanisms to Obtain PA for Medical Benefit Drugs MD or SP calls or Web-based Portal faxes health plan • Labor intensive • Questions relevant to condition • Significant lag time • Immediate authorization

Load more