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66 Cards in this Set
- Front
- Back
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some adoptions for pharmacist services has occurred where (3)
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Some Medicaid programs.
Some employers, especially self-funded. Medicare Part D |
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Models for Adoption of Insurance Coverage (3)
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risk pooling model
demand model cost containment model (models on how insurance evolves) |
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risk pooling models- coverage evolves because?
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coverage evolves because the cost of service is catastrophic and unpredictable.
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risk pooling model- applies to pharmacist services?
what drives demand for coverage? |
Consumer drives demand for coverage.
Does not apply to pharmacist services. |
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what would happen if there was a nice PBM that just wanted to reimburse pharmacies more (3)
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cost would be passed on to beneficiaries- drug costs/premiums would go up
employers will not like this unless this increase in price is justified PBM will be at competitive disadvantage |
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How did coverage evolved for hospital service?
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idk started out with risk pooling models
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True insurance means there is a benefit from doing what?
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pooling risk
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demand model- coverage evolves because...
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coverage evolves because consumers demand the service
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demand model fueled by...
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Fueled by “prepayment” health insurance system
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How insurance coverage for dental care and vision care evolved.
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demand model
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Employees benefit in demand model by having services covered by insurance even though they are not catastrophic and unpredictable vs. paying cash for them as needed. Why? (3)
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employees benefit if employer pays part of it (subsidizes) so employees demand coverage of services through their employer health plan
also cash paying is usually more costly for patient (no bargaining power) tax subsidies- not tax deductible if you pay cash |
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example of health care profession that has successfully lobbied demand model insurance
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Chiropractors are an example of a health care profession that has used lobbying successfully.
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Easier to get benefit mandate if ...
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both consumer groups and provider groups are lobbying in support.
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how to get demand model to work to provide coverage for a service
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Consumers or providers also can lobby legislators to get benefit mandates passed. (Force insurers to cover a particular service)
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cost containment model- coverage evolves because...
insurers cover service on what condition? |
coverage evolves because third party payer believes the services reduces other health care costs in a relevant time frame.
Insurers cover service if it provides savings on other claim costs that are greater than reimbursement for the “cost-containing” service |
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cost containment model- possible role in coverage for what?
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Possible role in coverage for preventive services.
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Key strategy being used by pharmacy profession (which model)
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cost containment model
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Why has third party coverage for pharmacist services been slow to evolve? (4 possibilities)
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Insurer reluctance to cover as a benefit?
Pharmacist/pharmacy reluctance to provide? Patient reluctance to receive/pay? Employer reluctance to pay? prob all of them |
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insurer reluctance to cover pharmacy services might stem from what 3 reasons?
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Pharmacist services not routinely provided in the cash market.
Insurers may be unaware of or not believe studies on cost-savings from pharmacist services. They may believe results from studies don’t apply because they studied diff populations or time frames |
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2 reasons why pharmacist services not being offered in cash market affects insurer reluctance to cover
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Key third party decision makers have no experience with pharmacist services because there are none...
No client demand for third party coverage..because there are none |
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Employees benefit in demand model by having services covered by insurance even though they are not catastrophic and unpredictable. Why? (3)
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employees benefit if employer pays part of it (subsidizes) so employees demand coverage of services through their employer health plan
also cash paying is usually more costly for patient (no bargaining power) tax subsidies- not tax deductible if you pay cash |
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example of health care profession that has successfully lobbied demand model insurance
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Chiropractors are an example of a health care profession that has used lobbying successfully.
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Easier to get benefit mandate if ...
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both consumer groups and provider groups are lobbying in support.
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how to get demand model to work to provide coverage for a service
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Consumers or providers also can lobby legislators to get benefit mandates passed. (Force insurers to cover a particular service)
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cost containment model- coverage evolves because...
insurers cover service on what condition? |
coverage evolves because third party payer believes the services reduces other health care costs in a relevant time frame.
Insurers cover service if it provides savings on other claim costs that are greater than reimbursement for the “cost-containing” service |
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cost containment model- possible role in coverage for what?
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Possible role in coverage for preventive services.
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Key strategy being used by pharmacy profession (which model)
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cost containment model
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Why has third party coverage for pharmacist services been slow to evolve? (4 possibilities)
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Insurer reluctance to cover as a benefit?
Pharmacist/pharmacy reluctance to provide? Patient reluctance to receive/pay? Employer reluctance to pay? prob all of them |
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insurer reluctance to cover pharmacy services might stem from what 7 reasons?
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Pharmacist services not routinely provided in the cash market.
Insurers may be unaware of or not believe studies on cost-savings from pharmacist services. They may believe results from studies don’t apply because they studied diff populations or time frames Uncertainty in how to determine/limit who gets services and enforce Pharmacies as suppliers, not pharmacists as providers Moral hazard Lemons problem |
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2 reasons why pharmacist services not being offered in cash market affects insurer reluctance to cover
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Key third party decision makers have no experience with pharmacist services because there are none...
No client demand for third party coverage..because there are none |
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Pharmacy/Pharmacist Reluctance- stems from what reasons (3)
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Historically, pharmacists have not routinely provided and charged for non-dispensing related services
Pharmacy systems set up to dispense products. Historical dependence on the prescription product as the source of revenue. |
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patient reluctance reasons (2)
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Patients unfamiliar with pharmacist services.
Patients unaware of need for services |
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employer reluctance reasons (4)
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Pharmacist services not routinely provided in the cash market.
Many employers concerned more with short term costs and may not believe pharmacist services will lower short term costs. Key employer decision makers have no experience with pharmacist services. No employee demand for third party coverage |
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Questions/Challenges Associated with Third Party Payment for Pharmacist Services (5)
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What patients are eligible for services?
Who can provide the services and how? Who do you pay, the pharmacy or the pharmacist- if you pay pharmacists do they have to have affiliation with pharmacy? How do you pay the pharmacy/pharmacist? How do you charge the employer or other payer? |
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patients eligibility for services- 2 options
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All enrollees or only patients with certain diseases or high number of meds (targeted beneficiary approach)?
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who can provide pharmacist services and how to provide them- what issues arise here (3)
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All pharmacists or only pharmacists with special training or credentialing?
Other non-pharmacist personnel- roles Face to face only or other methods? |
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ways to pay pharmacist for services (4)
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Fee for service or capitation?
Time based (paid by how much time spent on patient) vs Outcome or action based- does there have to be drug therapy change to be paid? |
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issues with how much to pay pharmacist for servies
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not sure what amount? Lack of established “usual and customary” rates.
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issues with billing process with pharmacist services (3)
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What billing platform and process?
what documentation requirements to show service was provided? What billing codes- tons of billing codes on medical side (now have CPT codes for pharmacy but still new) |
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2 ways to charge employer/payer for service
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Charge for each service used or capitation?
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What are costs to pharmacists of obtaining third party reimbursement for their services? (3)
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takes time and money to develop a system of reimbursement- administrative complexity
reimbursements will probably go down over time for pharmacist services pharmacist will lose flexibility- usually can provide whatever they want to whoever they need- now it will all be determined by contract (what is paid for, who is eligible) |
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What are benefits to pharmacists of obtaining third party reimbursement for their services?
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moral hazard working for the profession- if you give insurance to pt they will use it more- important in a new market
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Asheville Project- what was it?
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The city manager of Asheville, NC set up a program to pay pharmacists to provide extra services to Asheville city employees with diabetes.
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asheville project- copays
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Copayments for diabetes supplies and drugs were waived.
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asheville project study- validity of methodology?
what did it show? |
Study (flawed design) showed large (but not statistically significant) savings in other (non-Rx) health care costs.
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What are costs to employers and insurers of having pharmacist services as a covered benefit in health insurance plans (2)
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extra costs from pharmacy services
invest a lot of time and effort to set up protocols for coverage, billing, etc. |
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What are benefits to employers and insurers of having pharmacist services as a covered benefit in health insurance plans (2)
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marketing benefit- more coverage may be more attractive
better healthcare- reduction in health care costs |
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A number of state Medicaid programs pay pharmacists for clinical services above and beyond dispensing. give examples of states/programs (4)
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Iowa Medicaid pays for pharmaceutical case management.
Missouri has a disease management program that pays primary care providers and pharmacists to collaborate to improve outcomes. Some states pay for specific services such as smoking cessation. Wisconsin and Minnesota pay for medication therapy management (MTM). |
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Outcomes Pharmaceutical Health Care- what is this
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Iowa company established by pharmacists to facilitate provision of and payment for pharmacist services.
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company model for Outcomes Pharmaceutical Health Care (3 goals)
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Create demand (clients- employers willing to pay/go for this)
Create supply (pharmacists) Build interface (web platform for documentation) |
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Which goal was the hardest for Outcomes to create?
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pharmacist supply- wtf
most pharmacies set up just to dispense |
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outcomes clients- primarily whom?
who else? (5) which client group has grown substantially |
clients were primarily self-insured employers.
Clients currently include Medicare Part D plans, state Medicaid programs, commercial insurers, self-insured employers, and unions. Medicare Part D business has grown substantially |
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Outcomes pays who to do what?
specific services are initiated by whom? |
They pay community pharmacists to provide face to face medication therapy management (MTM) services
Some services are pharmacist initiated and others are plan initiated |
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Outcomes pay model for clients and pharmacists
guarantees |
capitation approach (monthly fee) to charge their clients, but uses a fee for service approach to pay pharmacists.
Have performance guarantee for clients. |
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Outcomes-growth
mostly pay pharmacies or pharmacists? |
Mostly pay pharmacies, not pharmacists.
Significant company growth in recent years. |
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Iowa Benefit Mandate Efforts- what's going on with this
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Iowa Pharmacy Association has been lobbying to get a benefit mandate for pharmacist services in Iowa.
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first bill of iowa benefit mandate efforts
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In 2009, a bill was introduced in the Iowa legislature to “encourage” private insurance companies to pay for MTM where MTM “means the same as pharmaceutical case management services under the Iowa Medicaid program. just a BILL not a LAW
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why did iowa benefit mandate bill not pass (who opposed it and why)
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iowa medical society- BOOOO
because it was a turf battle...they felt that pharmacists were encroaching on physician territory |
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2010 iowa benefit mandate bill
did it pass? |
In 2010, a bill was introduced on the Iowa Legislature that would require private insurers to pay for pharmacist MTM
NOPE NOPE NOPE |
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2010 iowa benefit mandate bill vs. 2009 version- what was different (2)
who did it apply to |
Included scope of practice language- worked with medical society to get them neutral about it
Would apply to individual and group private health insurance policies that cover prescription drugs (except self-funded employers- by fed law exempt from state law). |
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why did the 2010 iowa benefits mandate bill not pass (who opposed and why)
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insurance companies- will always oppose mandates because they have to increase premiums and it fucks it all up
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most recent iowa benefits mandate strategy
did a bill come out of this? |
More recently, strategy has been to try to get coverage of MTM as a benefit for Iowa State employees via a short pilot program covered by Outcomes
In 2012, both the Iowa House and Senate passed a bill that contained language to add MTM as a covered benefit for state employees |
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why did the 2012 bill not pass (2)
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governor vetoed it...because MTM would probably cost more
should do it through private means not gov mandate |
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two things in the Patient Protection and Affordable Care Act of 2010 that pertain to MTM (2)
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Multiple programs that Medicare Advantage plans can implement to receive a bonus, and one of these is having an MTM program that is more extensive than required under Part D (one way to get bonus)
Grants and contracts in MA to implement MTM programs will be available |
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Grants and contracts program for MTM in MA- requirements (3)
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MTM must be provided by a licensed pharmacist.
Specific MTM requirements are listed. Must be offered to targeted beneficiaries (certain properties) |
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characteristics of targeted beneficiaries of MTM for grants/contracts eligibility (4)
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4 or more prescribed meds or
Any “high risk” medication 2 or more chronic diseases Transition of care or other factor that is likely to create high risk of medication related problems. |
