Payer-providers

Be better prepared to face new industry standards in terms of the commercial operating model (including market access, pricing, payer/provider relations), as well as regulatory affairs, quality, and drug safety ... 

PBMs are also characterized by a series of relationships among many stakeholders payers, providers, consumers, and pharmaceutical companies. Payers include employers, employer coalitions, insurers, managed care organizations, Medicare, and Medicaid. Typically, they pay the net prescription cost and a per claim or transaction fee to the PBM for claim processing. Money and information flow back to the payers in the form of rebates and a variety of utilization reports. 

Over the past three decades, we have seen the emergence of two major influences in decisions about new advances in healthcare. These are the payer-providers and the patient-consumers. Their role in the decision-making process has increased rapidly in the last 25 years, as can be seen in Figure 2.1. 

For my part, as good as the definitions are, only Holstein comes close to the pivotal ingredient—the payer-provider relationship. My belief is that DM functions best when it is the product of a binding contract that is based on whole treatment protocols that have regard to quality and efficiency and that are delivered in a way most appropriate for patients. They are also founded in rewards for success and penalties for failure. I see DM as more than a management tool. I believe it to be a management lever—for change. 

HelUnger and Fleishman (2000) derived estimates for costs of treating people with HIV disease in the United States using patient-based, payer-based, and provider-based approaches. Based on insurance data from 1996, they calculated average annual cost of treating a person with HIV disease between US 20,000 and US 24,700. 

This book, which incorporates materials written by some of the finest minds in pharmacy practice and education, can enable the reader to play a crucial role in improving the drug use process for patients, providers, payers, and society. The purpose of this book is to help hone your skills so you can make a real improvement in the therapies you provide to your patients. Current and future clinicians can rely on the information laid out here to enhance your knowledge and allow you to assist your patients with the sound advice that they expect you to provide. Use the text, case histories, and numerous examples detailed here to expand your therapeutic skills, and to help positively impact your patients in the years to come. 

Currently, physicians and patients determine the demand for pharmaceuticals and employers and insurers assume the risk and cost. As the price of new health care technologies escalates, payers will design and implement strategies to share risk and cost. Defined employer contributions, increased patient cost sharing, and benefit exclusions will be used to help control utilization and cost. In this environment, value-based assessments will be crucial to the adoption of any technological innovation. It is reasonable to expect public and private coverage for new therapies if evidence is provided regarding the costs and consequences of treatment. However, social and ethical dilemmas will certainly arise as therapies whose costs exceed their benefits are debated in the public arena. 

Economists have long emphasized that in health care, identification of the consumer is ambiguous. Is it the patient, the physician acting as a professional agent on behalf of the patient, or is it the third-party payer In most but not all countries, pharmaceutical manufacturer sales representatives, called detailers, are permitted to visit physicians in their offices and provide them with promotional material. Representatives from pharmaceutical manufacturers also interact with public-sector payers such as ministries of health, as well as with private-sector payers, such as insurers and self-insured employers in the United States. 

Medicines Regulation, it did not even consider the possibility of consumer-directed promotions, but only envisaged rather technical information promotions to health care providers and payers. Thus, since it seemed to be impossible, DTCA was not explicitly prohibited in New Zealand. 

Along the Y axis are four points of view, or perspectives, that one may take in carrying out an analysis. One may take the point of view of society in assessing the costs and benefits of a new medical therapy. Alternatively, one may take the point of view of the patient, the payer, or the provider. Along the third axis, the Z axis, are the types of costs and benefits that can be included in economic analysis of medical care. These costs and benefits, defined below, include direct costs and benefits, productivity costs and benefits, and intangible costs and benefits. 

The third axis in Fig. 1 is that of the perspective of an economic analysis of medical care. Costs and benefits can be calculated with respect to society s, the patient s, the payer s, and the provider s points of view. A study s perspective determines how costs and benefits are measured, and the economist s strict definition of costs (the consumption of a resource that could otherwise be used for another purpose) may no longer be appropriate when perspectives different from that of society as a whole are used. For example, a hospital s cost of providing a service may be less than its charge. From the hospital s perspective, then, the charge could be an overstatement of the resources consumed for some services. However, if the patient has to pay the full charge, it is an accurate reflection of the cost of the service to the patient. Alternatively, if the hospital decreases its costs by discharging patients early, the hospital s costs may decrease, but patients costs may increase because of the need for increased outpatient expenses that are not covered by their health insurance plan. 

With so much bureaucracy to support it should not be surprising to realize that the FDA is an expensive unit of the federal government paid for by the tax payer. With this in mind Congress has recently allowed fees to be imposed, allowing the companies who will benefit to provide some support. 

The pharmaceutical industry has an important social contract with the public to discover and develop medicines that have value in extending and enhancing life. Simultaneously, the industry must maintain its profitability both to ensure the future stream of innovations and to provide investors with a return. Balancing the responsibilities to the public and to shareholders is further complicated by the inefficiencies of the global patent system, the disease burden of poor developing countries, national price control systems, and third-party payers. 

Credit cards List by issuer and card number. Make sure the payer is provided access to accounts. Ask that these accounts be paid immediately and cards destroyed. 

So what does this mean for pharmacy practice More pharmacists must understand continuous quality improvement and be able to develop, implement, and measure the outcomes of such a plan. This could provide an opportunity for a community pharmacy report card (quality measurement) system on which pharmacies can compete on the basis of quality. Such a system may provide a great opportunity for pharmacies to advertise quality outcomes to payers and patients. If such a system is successful, quality could drive patient choices and payer decisions. Ultimately the pharmacies with the highest quality may get more market share or obtain higher reimbursement rates for certain services. 

A pharmacist also is likely to make use of interpersonal communication skills when interacting with patients and other practitioners such as physicians. Training in these skills is essential. For example, pharmacists may need practice and critical feedback in writing effective SOAP (subjective, objective, assessment plan) notes to be sent to physicians. It is important that pharmacy personnel develop confidence in their ability not only to provide new pharmacy services but also to market their services to all groups of consumers (i.e., patients, health care providers, and payers). 

The last marketing-mix variable is productivity and quality. One issue here is creating efficiency in pharmacy service activities. This means that monitoring and feedback of service encounters should be performed. Then pharmacists can be trained to be efficient in the time spent with patients when providing services. Time benchmarks can be established for various service offerings. Nonpharmacist personnel should be used where appropriate, such as in scheduling appointments and billing payers. 

While learning more about potential value-added pharmacy services, it is a good idea for business planners to speak with others about their ideas. Many pharmacists who have already developed value-added services will gladly share what they have learned. Visiting a setting where value-added pharmacy services are already in place not only provides evidence of how these services actually work but also will answer many questions pharmacists may have later in the planning process. Other pharmacists, technicians, and pharmacy employees may have experienced value-added services in their prior practice experiences and may provide insights into how they work. Other health care professionals can provide feedback about additional services that they or their patients may need. Payers [e.g., in-... 

Before Dr. Brouchard can begin providing these services, he wants to make sure that his program is financially feasible. To do this, he needs to explore ways to be compensated for his services. He is familiar with being compensated for durable medical equipment, so he knows the pharmacy can bill for blood glucose meters, but he has never tried to bill third-party payers or patients for other types of services. 

Compensation traditionally is provided by a patient (e.g., first-party payer) or by an insurance carrier (third-party payers). With first-party payers, the fee for the service is requested directly from the patient. There are advantages and disadvantages to charging patients directly for a clinical service. Advantages include the fact that the pharmacist can ask directly for and... 

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